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    diah utami
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    This morning report summarizes a 2-year-old patient presenting with cough, shortness of breath, and fever for 2 weeks. On examination, the patient has tachycardia, tachypnea, hypoxemia, and respiratory distress. Chest x-ray shows bronchopneumonia. The patient is diagnosed with bronchopneumonia and anemia. Treatment includes oxygen, IV fluids, antibiotics, bronchodilators, paracetamol, and a blood transfusion. Over subsequent days the patient's symptoms and vital signs improve with treatment.

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    This morning report summarizes a 2-year-old patient presenting with cough, shortness of breath, and fever for 2 weeks. On examination, the patient has tachycardia, tachypnea, hypoxemia, and respiratory distress. Chest x-ray shows bronchopneumonia. The patient is diagnosed with bronchopneumonia and anemia. Treatment includes oxygen, IV fluids, antibiotics, bronchodilators, paracetamol, and a blood transfusion. Over subsequent days the patient's symptoms and vital signs improve with treatment.

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    © All Rights Reserved
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    11 views14 pages

    PTT Morpot

    Uploaded by

    diah utami
    This morning report summarizes a 2-year-old patient presenting with cough, shortness of breath, and fever for 2 weeks. On examination, the patient has tachycardia, tachypnea, hypoxemia, and respiratory distress. Chest x-ray shows bronchopneumonia. The patient is diagnosed with bronchopneumonia and anemia. Treatment includes oxygen, IV fluids, antibiotics, bronchodilators, paracetamol, and a blood transfusion. Over subsequent days the patient's symptoms and vital signs improve with treatment.

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    © All Rights Reserved
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    of 14

    MORNING REPORT

    An. Qiana Nazeefa/2th

     Observasi Dipsneu
     Bronkho Pneumonia
     Anemia
    Alloanamnesis
     Keluhan Utama : Batuk, Sesak, dan Demam

     Os datang diantar oleh kedua orang tuanya dengan keluhan sesak nafas sejak 2 minggu
    smrs. Sesak terus menerus disertai demam, batuk, dan flu.
    Os juga tidak mau makan dan lemas, BAB dan BAK tidak ada keluhan.
    Os sudah berobat ke klinik tapi tidak ada perubahan, lalu os dibawa ke IGD RSUD
    Kab. Bekasi
    PEMERIKSAAN FISIK DAN TANDA VITAL

     Kesadaran : Composmentis, AVPU = Alertness


     Nadi : 160x/ menit
     Respirasi : 40c/menit
     Suhu : 36,7
     SpO2 : 69% RA - 96% NC 2 lpm
     BB : 9,4 kg
    PEMERIKSAAN FISIK DAN TANDA VITAL

     Kepala ; dalam batas normal


     Leher ; Kelenjar betah bening tidak tetaba
     Thorax ; Retraksi intercostal
     Jantung : BJ 1 2 regular, M (-), G (-)
     Paru : Ronkhi +/+, wheezing -/-
     Abdomen : Supel, BU (+) normal, NT (-), H/L tidak teeraba
     Ekstremitas : Akral hangat, CRT < 20 menit
    Pemeriksaan Penunjang
    Pemeriksaan Penunjang
    Pemeriksaan Penunjang
    Diagnosis dan terapi

     Observasi Dipsneu
     Bronkhopneumonia
     Anemia
    Diagnosis dan terapi

    Terapi IGD :
     O2 2 lpm NC
     IVFD Kaen 3a 940/24 jm
     Inhalasi Combiven
    Diagnosis dan terapi
    Advice dr. Natalina Sp.A :
     IVFD Kaen 3a asnet
     Injek Cefotaxime 2x500 mg iv
     Injek Amikasin 1x135 mg iv
     Inhalasi lasalcom + Pulmicort 1 resfull /24 nam
     Infus Paracetamol 1x150
     Pulvis batuk 3x1
     Transfusi PRC 200cc
     Cek MDT pre transfuse
     Premededikasi injek furosemide 10 mg saat darah masuk
    CATATAN PERKEMBANGAN PASIEN
    TANGGAL CATATAN PERKEMBANGAN PASIEN KETERANGAN

    25/11/2022 S : Batuk, Sesak


    0 : KU TSS, Kes : CM Cek DR post
    N : 140x SpO2 : 98%
    S : 36,7 RR : 32x
    transfusi
    A : 1. Bronkhopneumonia
    2. Anemia
    P : BC / hari
    Inhalasi/ 12 jm
    Transfusi PRC 200cc, dengan premedikasi
    Aminophillin 4 x 24 mg
    Dexametason 2x1/2 ampul (3 hari)
    Terapi lain lanjut

    S : Batuk, Sesak
    26/11/2022
    0 : KU TSS, Kes : CM
    N : 120x SpO2 : 98%
    S : 36,5 RR : 30x
    A : 1. Bronkhopneumonia
    2. Anemia
    P : Terapi lanjut
    CATATAN PERKEMBANGAN PASIEN
    TANGGAL CATATAN PERKEMBANGAN PASIEN KETERANGAN

    27/11/202 S : Batuk, Sesak berkurang Post transfuse


    2 0 : KU TSS, Kes : CM Hb 14,8
    N : 120x SpO2 : 98% Ht 47%
    S : 36,7 RR : 28x Leu 33.600
    A : 1. Bronkhopneumonia
    2. Anemia
    P : terapi lanjut
    28/11/20 S : Batuk (+), Sesak (-)
    22 0 : KU TSS, Kes : CM
    N : 120x SpO2 : 98%
    S : 36,7 RR : 28x
    A : 1. Bronkhopneumonia
    2. Anemia
    P : terapi lanjut
    TERIMAKASIH

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