MORNING REPORT

SELASA, 26 JULI 2016

• Mrs. hayati, 55 years old CM :
• Jakarta TC : Tuesday,
• Cc : Malaise date : 26 – 7- 16

Findings : Malaise
Phys Ex : Thorax :
LOC : E4 V5 M6, compos mentis I ; movement of chestwall symmetric
Pal : Vocal fremitus symmetric
BP : 90/50 MMhG Per : Sonor/sonor
PR : 100 X/ mnt Aus : basic breath sound vesicular ,
RR : 17 x/mnt Ronkhi -/-, whezeeng -/-, heart sound I & II
Temp : 36,80C regular, murmur (-) gallop (-)
Eye :
conjungtiva anemis -/- Abdomen :
Sclera icteric -/- Ins : stomach looks flat
Aus : bowel sound 4 times/mnt
Lab : Per : Typany, percussion pain (-)
Hematologi : Pal : supel, pressure pain (-)
Hb = 3,7 g/dl Ext : warm, capillary refill <2 ‘’ edema (-,-/-,-)
L = 6,5 ribu/ul
Ht = 13,3 %
Trob = 84 ribu/ul
GDS =512 mg/dl
Ureum = 61 mg/dl
Creatinin = 1,22 mg/dl
 Assessment Theraphy Planning

Anemia gravis + DM type 2 Pro Hospitalized

IVFD : III NS/24 jam Consule doctor Hanock,
Mm : Sp.PD
Novorapid Insulin 2 x 14 Diit : biasa rendah garam
(IV) Observation of lab: GDS,
Omeprazole 1 x 40 mg (IV) LED, Elektrolit
Blood Transfusion until Hb
> 10 g/dL
• Tn. Irwansyah, 27 years old CM :
• Jakarta TC : Tuesday,
• CC : Dyspnue Date : 26-7-16

Findings : Thorax :
Dypsnue Ins : movement of chestwall
symmetric
Phys Ex : Pal : Vocal fremitus symmetric
LOC : E4 V5 M6, compos Per : Sonor/sonor
mentis Aus : basic breath sound vesicular
BP : 100/60 mmHG ,Ronkhi -/-, whezeeng -/-, heart sound
PR : 52 X/ mnt I & II regular, murmur (-) gallop (-)
RR : 24 x/mnt Abdomen :
Temp : 36,50C Ins : stomach looks flat
Eye : Aus : bowel sound 4 times/mnt
conjungtiva anemis -/- Per : Typany, percussion pain (-)
Sclera icteric -/- Pal : Deffence Muscullar, pressure
pain (+) region supra pubic, lumbal
sinistra and inguinal sinistra
Ext : warm, capillary refill <2 ‘’
edema
Ext sup dex(-) et sin (-)
Ext inf dex (-) et sin (+)
• Lab :
1. Elektrolit :
4. ABG :
• Na = 129 mmol/L •Ph = 7,228
• K = 5,9 mmol/L •PCO2 = 11,7 L
• Cl = 94 mmol/L •PO2 = 175,4
•SO2 = 98,2
•BE = -19,8
•HCO3 = 4,9
•TCO2 = 5,3
2. Hematologi :
•Kons O2 = 12,6
•Hb = 7,0 g/dl
•L = 10,6 ribu/ul
5. Foto Thorax AP-PA (+)
•Ht = 21,7 %
•Trob = 235 ribu/ul

3. GDS =70 mg/dl

 Assessment Theraphy Planning

Dispepsia with some Diit : biasa rendah garam Pro Hospitalized

dehydration + metabolic IVFD : III NS /24 jam Consultation Surgery
acidosis + electrolit Mm : Department
imbalance + anemia Ceftizoxime 2 x 1 gr NGT 6 x 200 cc
Omeprazole drip 1 x 40 mg Observation fluid balance
Sucralfat syr 3 x 1 c Observation of lab: Ur, Kr,
Syringe pump bicnat 50 SGOT, SGPT
mEq/12 Jam Blood Transfusion until Hb
> 10 g/dL
• Ny Welsti Effendy, 36 years old CM :
• Jakarta TC : Tuesday,
• Cc : Abdominal pain Date : 26-7-2016
Findings : Thorax : Lab :
Abdominal pain Ins : movement of chestwall Hematologi :
symmetric Hb = 3,7 g/dl
Phys Ex : Pal : Vocal fremitus symmetric L = 6,5 ribu/ul
LOC : E4 V5 M6, compos mentis Per : Sonor/sonor
Ht = 13,3 %
BP : 150/100 mmHG Aus : basic breath sound vesicular ,
PR : 64 X/ mnt Ronkhi -/+, whezeeng -/-, heart sound Trob = 84 ribu/ul
RR : 20 x/mnt I & II regular, murmur (-) gallop (-) GDS =512 mg/dl
Temp :36,7 C0 Ureum = 61 mg/dl
Eye : Abdomen : Creatinin = 1,22 mg/dl
conjungtiva anemis -/- Ins : stomach looks flat
Sclera icteric -/- Aus : bowel sound 3 times/mnt
Per : Typany, percussion pain (-)
Pal : supel, pressure pain (+) region
epigastrica
Ext : warm, capillary refill <2 ‘’ edema
(-)
 Assessment Theraphy Planning

gastritis IVFD : Pro Hospitalized

II RL/24 jam Observation of vital sign
MM: Diit : soft food
Omeprazole drip 1 x 40
(IV)
Sucralfat syr 3 x 1 c
Domperidone 3 x 10 mg
Levofloxacin tab 1 x 500
mg
• Mr. dr. Petrus, 46 years old CM :
• Jakarta TC : Tuesday,
• CC : Fever Date : 26-7-16

Findings : Thorax : Lab :

Fever at night Ins : movement of chestwall Hematologi :
Shiver symmetric Hb = 14,4 g/dl
Headache Pal : Vocal fremitus symmetric L = 4,5 ribu/ul
Abdominal pain Per : Sonor/sonor
Ht = 45,7 %
Phys Ex : Aus : basic breath sound vesicular,
LOC : E4 V5 M6, compos Ronkhi -/-, whezeeng -/-, heart sound Trob = 187 ribu/ul
mentis, tampak sakit berat I & II regular, murmur (-) gallop (-)
BP : 118/80 mmHG
PR : 79X/ mnt Abdomen :
RR : 21 x/mnt Ins : stomach looks flat
Temp :360C Aus : bowel sound 5 times/mnt
Eye : Per : Typany, percussion pain (-)
conjungtiva anemis -/- Pal : supel, pressure pain (-)
Sclera icteric -/- Ext : warm, capillary refill <2 ‘’ edema
(-)
 Assessment Theraphy Planning

Viral infection IVFD : Pro Hospitalized

III RL/24 Jam Diit: Nasi Tim
MM: Observation of vital sign
Omeprazole drip 1 x 40 g
(IV)
Paracetamol 3 x 500 mg
Vit. B Comp2 x 1 tab
• Mr. Bayu Setiawan , 33 years old CM :
• Jakarta TC : Tuesday
• CC : Dyspnea Date : 26-7-16
Findings : Thoraks: Lab :
Cough with phlegm ins: movement of chest wall Hematologi :
Fever symmetric Hb = 12,6 g/dl
Night sweats Pal: VF symmetric L = 8,3 ribu/ul
Per: sonor sin=dex
Ht = 38,4 %
LOC: E4M6V5, compos mentis Aus: Basic breath sounds vesiculer, r -
BP: 120/80mmHg /+, wh -/-, heart sound I and II reguler Trob = 295 ribu/ul
PR: 92x/min murmur (-), gallops (-)
RR: 36x/min
Temp: 36 C Abdomen:
Head: normocephali ins: stomach looks flat
Eye: Aus: bowel sound 4x/min
Conjungtiva anemis +/+ , SI -/- Per: tympani, percussion pain (-)
Pal: supple, palpation pain (-)
Ekstremity: cold (-), crt <2 sec
 Assessment Theraphy Planning

Bronkopneumonia -ranitidine 1 ampul pro hospitalized

-inject plug -ECG
-abdomen rontgen (3
position)
-NGT