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MORNING REPORT

INTERNA DEPARTMENT
EMERGENCY ROOM

IDENTITY

Name
: Mrs. Kastini
Age
: 50 y.o
Sex
: Female
Address
: Landean RT2 RW1 Klotok Plumpang
Tuban
Date of examination : August 26th, 2015

ANAMNESIS
Chief complaint

Shortness of breath
Present Illness History

Patient was refered from Muhamadiyah Babat Hospital with chief


complaint short of breathness since 5 days ago. Patient felt short of
breathness continously and get worse if she did an activity, lying
and walking for about 10 m. Patient usually sleep with one pillow,
she often wake up in the middle of the night for miction. Nauseous
(+) and vomit (+). Vomitting for about 3 times and contains foods.
She also felt itchiness both in her legs and arms. Cough (-). Chest
pain -. Pain in her stomach (+), felt like stabbed. Pain when miction.
Defecation within normal line. Decrease in apetite.

Past Illness History : Hipertension uncontrolled,


Diabetes Mellitus for 5 years used insulin but
didnt routine controlled in mantri. Hemodialisa
history (-).
Family Illness History : -

PRIMARY SURVEY
A: clear, gargling (-), speak fluently (-), potensial
obstruction (-)
B: spontan, RR: 36x/mnt, kusmaul breathing,
ves/ves, Rh+/+, wh-/-, SaO2 100% with NRM O2
10lpm
C: akral Cold, Dry, Pale, CRT <2, PR: 93x/mnt, BP:
195/100 mmHg
D: GCS 345, lateralisation -, Round Pupil isokor 3
mm/3mm, LR+/+
E: temp 36C, urine output 100 cc

SECONDARY SURVEY
H/N
: a+/i-/c-/d+,
Chest
: sim/sim, ret+/ret+
Lung
: ves/ves Rh+/+ wh-/ Heart
: S1 S2 single, murmur -/-,
gallop -/ Abdomen : soepel, met -, bowel sound +
normal, H/L unpalpable, Epigastric pain (+)
Extremity : aic -/-, CDP, pretibia edema

PLANNING DIAGNOSIS
DL
SE
RFT
LFT
Thorax photo
ECG
Blood Gas Analysis
UL
Keton

LABORATORY FINDING
GDA : 361 mg/dl
Eritrocyte : 1.95
Hematocrit : 19
%
Hb : 5.7 mg/dl
Limphocyte: 4.5
Basophil: 2.4
Eosinopil : 1.8
Monocyte : 1.6
Leucocyte :
19.000
Neutrophyl: 89.7
Trombocyte :
661.000

Chloride : 107
Natrium : 142
kalium 6.0
Ureum 170
Kreatinin : 7.2
Be : -11.8
Beecf: -12.8
HCO3 : 14.8
PCO2 : 47
pH :7.150
PO2 : 194
SO2 : 99
SGOT : 28
SGPT : 59

THORAX AP
TIDUR

ECG

CLUE AND CUE

Female, 50 y.o
Dyspnea continously
nauseous and vomit
itchiness
Hypertension
Anemis
Rhonchi +/+
hiperglikemi
hiperkalemi
azotemia
Leukocytosis
Asidosis metabolic

ASSESMENT

Hypertension Emergency
DM type II
SIRS
Anemia
Hyperkalemia
Asidosis metabolic
ALO
CKD

PLANNING THERAPHY

Half sitting position


O2 mask 10 lpm
DK
IVFD PZ lifeline
Inj Furosemid 2 amp residu > 200 cc, BP 134/100 ->
furosemid 3x1 amp
Inj Sulperazone 2x1 gr
Inj Ca Glukonas 10 cc bolus D40+2IU insulin, 3 x interval
one hour check Kalium + Random Blood Glucose
RCI 3x4 IU if Random Blood Glucose > 250 post kalium
correction
Pro transfusion 1kolf/day premed furosemid 1 amp
Consult: Internist, Anesthesia Specialist

PROGNOSIS
Dubia ad malam

Patient compliance
Vital sign
urination production

Explain to the patients family about the


diagnosis, etiology, intervention of therapy,
complication, and prognosis.