MORNING REPORT

7TH JUNE, 2017

DEPT OF INTERNAL MEDICINE
G 26
 PASIEN INTERNA
Ny W, 50 th CKD + IHD + Pleural Effusion
Marwah 17
Ny M, 53 th CHF + Pleural Effusion Marwah10
Ny G, 65 th Pneumonia Shofa 16
Tn K, 64 th Ulkus Pedis + Sepsis Marwah 17
Tn M, 49 th ARF Marwah 11
 IDENTITY

Name : Mrs. W
Age : 50 years old
Address : Sembung, Sukorame- Lamongan
Admission : 7th June, 2017 14:27
 Chief Complaint

Shortness of breath

Present history

Patient come to IGD RSML with complaint shortess of breath

since 2 months before entering the hospital, become heavy
5 days before. Shortness of breath that occurs if she is lie
down, sleeps with 3-4 pillows, chest pain (+) until her back,
nausea (+), vomiting (+) 2 days before, abdominal pain (-),
headaches (-), cough phlegm, coughing since 5 days,
reduce of urination, normal defecate. Patient complains
oedema both of his leg since 2 week ago.
 Past history of Illness

DM denied
HT + since 3 years ego
Ever treated at hospital with same complains
Never dialysis

Family history

DM and HT denied
 Social history

She consumed jamu once a week, alcohol -, coffee -

 VITAL SIGNS

Pulse
92x/min
BP
139/87 mmHg
Temp
36.5C
RR
32x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 32x/min, ves / ves, rh + basah basal/-,
wh -/-, SaO2 91% without O2 support
C: extremity WDR, CRT <2, N 92x/min, TD 139/89
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36.5 C
GENERAL STATUS
 General condition : looks weak
Awareness : compos mentis
GCS : 456
H/N : a -/i-/c-/d+ retraksi
intercostae, JVP increased R+2 90
 THORAX
Inspection
Symmetrical, retraction +/+
Palpation
Fremitus (dbn), thrill (-)
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh + basah basal/-, wh -/-
Cor: S1 S2 single, mur -, gall-
 ABDOMEN
Inspection
distended, collaterral veins (-), inflammation signs (-),
operation wound (-)
Auscultation
Abdomen sound + N
Palpation
Epigastric pain (-)
Liver/Spleen, renal is untouchable
Percussion
tymphany
 EXTREMITIES
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)
Palpation
WDR, CRT <2 , leg pitting oedem +/+
 CLUE AND CUE

Female 50th
Shortness of breath
Chest pain
Cough phlegm
Rh + basah basal /-
JVP increased R+2 90
Dyspneu with retraksi intercostae
Leg pitting oedem +/+
 ASSESMENT

CKD
CHF
 PLANNING DIAGNOSE

Blood Test (DL)

RFT (Renal Function Test)
ECG
Ro Thorax
LABORATORY FINDINGS
GDA 116 Eosinofil 1.6
Kalium 5,8 Basofil 0.6
Na 135 Eritrosit 2.72
Clorida 107 Hb 7.2
Urea 171 Hct 22.1
Creatinin 13.0 MCV 81.30
Leukosit 11.4 MCH 26.50
Neutrofil 77.2 MCHC 32.60
Limposit 14.3 RDW 13
Monosit 6.3 Trombosit 306
MPV 3
RO THORAX
ECG
 RE-ASSESMENT

CKD
IHD
Pleural Effusion Dextra
Anemia
 PLANNING THERAPY
O2 NRM 10 lpm SpO2 91 % 100 % , RR 32 26
Inf. PZ life line
DK residu 50 cc
Inj Lasik 2 amp
Inj Ceftriaxone 2x1 gr
Ca Glukonas 1 amp + D40 % + Novorapid 2 IU
3 times
Transfusion PRC 1 kolf/day
PO Kelitage 3dd I scht
 PLANNING MONITORING

Vital Signs
Patients complaint
 PLANNING EDUCATION

Explain to the patien and his family about the

disease, cause, stadium of the disease,
complication, intervention of the therapy and
prognosis.