Mr. MS, an 80-year-old Hindu man, was admitted to the emergency room of Wangaya Hospital on December 8, 2015 for shortness of breath, body heat, weakness, and lack of appetite. He was diagnosed with septic shock and suspected pneumonia. His medical assessment found an ineffective airway, rapid breathing, low blood pressure, and decreased consciousness. The patient reported feeling hot, weak, and with decreased appetite and drinking that day, before developing shortness of breath and decreasing consciousness in the afternoon.
Mr. MS, an 80-year-old Hindu man, was admitted to the emergency room of Wangaya Hospital on December 8, 2015 for shortness of breath, body heat, weakness, and lack of appetite. He was diagnosed with septic shock and suspected pneumonia. His medical assessment found an ineffective airway, rapid breathing, low blood pressure, and decreased consciousness. The patient reported feeling hot, weak, and with decreased appetite and drinking that day, before developing shortness of breath and decreasing consciousness in the afternoon.
Mr. MS, an 80-year-old Hindu man, was admitted to the emergency room of Wangaya Hospital on December 8, 2015 for shortness of breath, body heat, weakness, and lack of appetite. He was diagnosed with septic shock and suspected pneumonia. His medical assessment found an ineffective airway, rapid breathing, low blood pressure, and decreased consciousness. The patient reported feeling hot, weak, and with decreased appetite and drinking that day, before developing shortness of breath and decreasing consciousness in the afternoon.
IN THE EMERGENCY ROOM OF WANGAYA HOSPITAL ON 08 DECEMBER 2015
1. Ainul Yatim 7. Fanita R
2. Arina Fitri 8. Jihan Pratiwi
3. Disa Aisyah 9. M. Dikky S.W
4. Dodi Iskandar 10. Sri Utami
5. Eka Afridayanti 11. Nur Hasanah
6. Fajar Ibnu 12. Sumiyati
• Name : Mr. MS PATIENT IDENTITY • Age : 80 years • Male gender • Occupation: Not working • Hindu religion • Hospital Entry Date : December 8, 2015 • Reason for entry: shortness of breath, body heat, weakness, does not want to eat and drink
• Medical Diagnosis : Septic shock + Susp. Pneumonia
PRIMARY SURVEY AIRWAY DISABILITY Ineffective airway clearance related to infection BREATHING GCS : E 3, V 3, M 4 Breathing Frequency: 25 x/minute EXPOSURE Oxygen Saturation : 95% There are no injuries CIRCULATION
Radial/carotid pulse: palpable, 100 beats/minute
Blood Pressure: 90/60 mmHg Peripheral Acral : Warm HISTORY • Since this morning the patient's body is hot and weak with eating and drinking only a little. In the afternoon the patient complained of shortness of breath and his consciousness had decreased Terima kasih