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MORNING REPORT

03 JANUARY 2019
Team: Fitri, Siti, Fitriatul, Dinda, Rusmin

SUPERVISOR: dr. I Gede Yasa Asmara, Sp.PD


RESUME
 Total patient: 8
 Still at IGD: 6

 Move to room
 O.Koko: 1
 Lakey: 1

 BPL: -
 Died: -
PATIENT 1
 Name : Ny. SN
 Gender : Female
 Age : 56 years old
 Adress : Dompu
 MR Number :611333
 Diagnose : CKD st V
 Other information : Move to Lakey (2003)
PATIENT 2
 Name : Ny. NKW
 Gender : Female
 Age : 80 years old
 Adress : Lingsar
 MR Number : 611339
 Diagnose : GEA mild dehidration
 Other information : Move to O.Kokok (203)
PATIENT 3
 Name : Ny. M
 Gender : Female
 Age : 34 years old
 Adress : Meninting, Lobar
 MR Number : 608769
 Diagnose : AMS ec susp enchepalopathy, sepsis
 Other information : Still at IGD
PATIENT 4
 Name : Ny. S
 Gender : Female
 Age : 19 years old
 Adress : Praya
 MR Number : 611340
 Diagnose : RHD MSI, CHF, TB Pulmo on treatment
 Other information : Still at IGD
PATIENT 5
 Name : Ny. WR
 Gender : Female
 Age : 20-12-1937
 Adress : Denpasar, Bali
 MR Number : 611361
 Diagnose : Septic, cellulitis pedis, post AF
 Other information : Still at IGD
PATIENT 6
 Name : Tn. AK
 Gender : Male
 Age : 01-05-1957
 Adress : Pancor
 MR Number : 611362
 Diagnose : Hepatoma
 Other information : Still at IGD
PATIENT 7
 Name : Tn. AZ
 Gender : Male
 Age : 27-12-1979
 Adress : Rumak Barat Selatan
 MR Number : 611357
 Diagnose : Hematemesis melena
 Other information : Still at IGD
PATIENT 8
 Name : Tn. F
 Gender : Male
 Age : 37 years old
 Adress : Sakra, Lotim
 MR Number : 611355
 Diagnose : Hepatoma, susp. Metastasis paru, Asites
 Other information : Still at IGD
PATIENT’S IDENTITY
 Name : Ny. NKW
 Age : 80 years
 Gender : Female
 Address : Lingsar, Lombok Barart
 Job :-
 No. RM : 611339
 Diagnosis : GEA
 Date of assessment : 03 january2019
ANAMNESIS

 Main Complaint  Diarrhea


 Current History of Disease

 Patients come to RSUP NTB with complaints of diarrhea since 3


days ago. frequency of diarrhea 4-5 x/day. The stools are liquid,
colour is yellow and a little bit of pulp but not accompanied by
mucus mixed with blood or colored like rice washing water. Before
diarrhea, the patient had a fever for 1 day ago and was taken to a
primary health care and had treated. Patients also complain of
nausea and vomiting when taking medication or eating. In
addition, patients also complain of abdominal pain that has arisen
since starting diarrhea.
 History of Past Illness
Previously, patients had diarrhea since a month ago, but didn’t arrive
at the hospital. hypertension (+) and routine take a medication,
diabetes mellitus (-), asthma (-), heart diseases (-). Patients were
treated at the damai pesona clinic with complaints of a diarrhea and
get therapy IVFD RL 30tpm, ranitidin tablet 2x1, scopma plus 3x1,
and zultrof forte 2x1.
 History of Family

History of similar symptoms (-), heart disease (-), hypertension (+),


diabetes mellitus (-), stroke (-), asthma (-)
 History of Allergic

History of food allergies (-), drugs (-)


GENERAL CONDITION
General Conditions : weakness
Awareness : Compos mentis (GCS E4V5M6)
Blood Pressure : 112/51 mmHg
Heart Rate : 163 x/minute
Respiratory Rate : 22 x/minute
Temperature : 37,4 C
SpO2 : 90% without O2
PHYSICAL EXAMINATION
Head
 Shape and size: Normocephali

 Facial edema: (-)

 Malar Rash: (-)

 N.VII Parese: (-)

 Mass: (-)

 Bleeding: (-)
PHYSICAL EXAMINATION
Eyes
 Position: Symmetrical
 Eyebrow: Normal
 Exophthalmus: (- / -)
 Ptosis: (- / -)
 Palpebra Edema: (- / -)
 Conjunctiva: Anemis (-/-)
 Sclera: Jaundice (-)
 Pupil: Isokor, 3 mm, round, pupillary reflex (+ / +)
 Cornea: Normal
 Lens: cloudy (- / -)
 Retroorbita compressive pain: (- / -)
 Sunken eyes : (-)
PHYSICAL EXAMINATION
Nose/Ear
 Symmetrical (+), deformity (-), septal deviation (-)

 Masses (-), lessions (-)

 Nasal lobe breath (-/-)

 Abormal secretions (-/-), bleeding (-)

Mouth
 Symmetrical mouth angle (+)

 Cyanosis (-), lessions (-)

 Gums, mucosa, and teeth are normal


PHYSICAL EXAMINATION
Neck
 Tracheal deviation (-)

 Masses (-), lessions (-)

 KGB enlargement (-), thyroid gland enlargement (-)

 SCM muscle enlargement (-)

 JVP increases (-)

 Carotid artery  reguler, adequate, bruit (-)


PHYSICAL EXAMINATION
Thorax
Inspection
 Shape and size are normal, symmetrical

 Chest wall movement: right and left symmetrical chest

 Chest surface: mass (-), scar (-), lessions (-)

 Used of breath-assisting muscles (-), retraction (-)

 Ribs and ribs: no widening or narrowing

 Jugular fossa: normal, supra and infraclavicular fossa are normal

 Ictus cordis pulsation (-)


PHYSICAL EXAMINATION
Thorax
Palpation
 Mediastium position is normal

 Right and left chest wall movement are symmetrical

 Press pain (-), lump (-), crepitation (-), masses (-)

 Ictus cordis is palpable on the ICS VII axilla line sinistra, thrill (-)
PHYSICAL EXAMINATION
Thorax
Percussion Sonor Sonor

 Pulmo’s density* Sonor Sonor


Sonor Sonor
 Heart border

Right : ICS VII parasternal line dextra


Left : ICS VII axilla line sinistra
 Border of pulmo-hepatic

Inspiration : ICS VI
Expiration : ICS IV
PHYSICAL EXAMINATION
Thorax
Auscultation Vesicular Vesicular
 Pulmo Vesicular Vesicular
Breath sounds* Vesicular Vesicular

Rhonki*
- -
Wheezing*
- -
 Cor
- -
S1 S2 single regular
Murmur (-) - -
Gallop (-) - -
- -
PHYSICAL EXAMINATION
Abdomen
 Inspection : Distention (-), masses (-), lessions (-), jaundice (-), collateral
veins (-), scar (-), striae (-), rash (-)
 Auscultation : Bowel sounds (+) normal, fr 16x/minutes, metallic sound
(-)
 Percussion* : Shifting dullness (-), undulation (-)
 Palpation :Tenderness(+) in the left side of abdomen, hepatomegaly
(-), splenomegaly (-), ballotement (-)
PHYSICAL EXAMINATION
Upper Extremity Lower Extremity
 Deformity (-/-)  Deformity (-/-)

 Warm acral (+/+)  Warm acral (+/+)

 Cyanosis (-/-)  Cyanosis (-/-)

 Clubbing finger (-/-)  Clubbing finger (-/-)

 Oedema (-/-)  Pitting oedema (-/-)


RESUME
A 80-year-old woman came to the RSUDP Province NTB with
diarrhea since 3 days ago with frecuency 4-5x/day, fever for 1
day before, nausea, vomiting, and abdominal pain arisen since
starting diarrhea.

From the physical examination, it was found that the general


condition is weakness compos mentis (GCS E4V5M6), blood
pressure 112/51 mmHg, heart rate 163 x/minute, respiratory
rate 22 x/minute, temperature 37,4 C, and SpO2 90% without
O2.
LABORATORY EXAMINATION
LABORATORIUM RESULT NORMAL VALUE

Haemoglobin 11,3 g/dL 12.0-16.0


Leukocytes 10050/uL 4000-10000
Erythrocytes 3.65 juta/uL 3.50-5.00
Platelets 231000/uL 150000-400000
Hematocrit 32 % 36-48
MCV 87,1 fL 80.0-100.0
MCH 31,0pg 26.0-34.0
MCHC 35,5g/dL 32.0-36.0
Urea 77 mg/dL 10-50
Creatinine 2,0 mg/dL 0.6-1.1
LABORATORY EXAMINATION
LABORATORIUM RESULT NORMAL VALUE

Blood glucose 115 mg/dL <160.00


Na 131 mmol/L 135-146
K 3,9 mmol/L 3.4-5.4
Cl 103 mmol/L 95-108
ECG
RONTGEN THORAX
 Cardiomegaly
 Aortosclerosis

 Pulmo Edema

 Efusi Pleura bilateral


ASSESSMENT
 GEA dehidrasi ringan
PLANNING (DIAGNOSTIC)
 Analisis Feses
PLANNING (THERAPY)
 IVFD RL 10 tpm
 Levofloxacin inj 500 mg/day

 Omeprazole inj 1 vial/ day

 Co cardiologist
THANK YOU