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Morning Report

September 28 , 2017
th

Dept. of internal medicine


H27
List Interna Medicine New Patients
1. Ny Rohmatul : DM type 2 + KAD + Electrolit imbalance
+ susp. SLE pro HCU
2. Tn. Salamun : IMA + ALO Shofa 2
Identity
Name : Mrs. R
Age : 46 years old
Address : Panceng, Gresik
Admission: September 28th, 2017 at 00:25
Chief Complaint

Fatigue
Present history

Patient felt fatigue since 3 day before admission and


complained swallowing pain since 5 days ago before
admission. She felt decreasing in apptetite, but she still
can drink enough. Patient also complained shortness
of breath since 4 days before admission and getting
worse since 12 hours before admission. Patient have
checked her health int the internist clinic and she was
suspected SLE but the laboratory test result didnt
come out
Past history of Illness

HT -, DM+ uncontrolled, susp. SLE

Family history

Family history:-
Social history

No social history related


Vital Signs
BP
167/79mmHg
Pulse
114x/min, strong, reguler
Temp
36,50 C
RR
36 x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 36x/min, ves / ves, rh +/+ basal wh -/-,
SaO2 97% without O2 support
C: extremity WDR, CRT <2, N 122x/min, BP
167/79mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,5 C
GENERAL STATUS
General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a-/i-/c-/d+
lymph node enlargement at neck (-)
Malar rash +, candidiasis oral +
Thorax
Inspection
Symmetrical, retraction-
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh /, wh -/-
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
Flat, Plak eritematous -
Auscultation
Meteorismus -, bowel sound WNL
Palpation
Liver and spleen WNL
Percussion
Tymphany
Extremities
Inspection
Anemis -, icteric (-), cyanosis (-), edema (+)
Palpation
Warm, dry, pale. CRT <2
CLUE AND CUE
Female. 46 y.o
Fatigue
Takipnea
Decrease of appetite
Decreasing body weight
Swallowing pain
Malar rash
Oral candida
Planning Diagnosis
DL
ECG
SE
BGA
Thorax photo
Assesment
DM type II
Susp KAD
Susp SLE
Laboratory Findings
Laboratorium
GDA 889 Eosinophil 0.6 (1-2)
Kalium serum 5,8 (3,6-5,5) Basofil 0.2 (0-1)
Natrium serum 123(135-155) Eritrosit 5,11 (3,8-5,3)
Clorida serum 89 ( 70-108) Hb 14,7(P 13-18 L 14-18)
Urea 70 (10-50) Hct 45.4 (L 40-54 P 35-47)
Serum creatinin 0,8(P 0,7-1,2 L 0,8-1,5) MCV 88.80(87.00-100)
SGOT 11 ( L 37, P 31) MCH 32.30(28.00-36.00)
SGPT 20(L 41, P 31) MCHC 30.80(31.00-37.00)
Leukosit 14,9 (4-11) RDW 160(10-16,5)
Neutropil 90.3 (49-67) Trombosit 433 (150-450)
Limfosit 3,8(25-33) MPV 6 (5-10)
Monosit 5,7 (3-7) LED 1 : 81 (0-1)
LED 2 : 101 (1-7)
PO2 : 148 (80.0- 100.0)
PCO2 : 11 ( 35.0-45.0)
PH : 7,146
cHCO3 : 3.7
Thb: 15.0
Be : -22.5
Beecf : -25,2
Re-Assesment

DM type 2
KAD
Electrolyte imbalance
Planning Therapy
O2 nasal 4 lpm
Loading PZ 2000cc/24 jam
Pump insulin 4 iu/jam
Inj santagesic 3x1
Inj ranitidin 2x50
Inj Ceftriaxone 2x 1 gr
Drip NaBic 50 meq/2jam
Pasang dk
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
PLANNING EDUCATION
Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.