Morning Report

August, 30th 2018

Dept. of internal medicine
J30
 OB LIST
1. Tn. Kadim  Nstemi
2. Ny. Manis  Stemi anterior
3. Tn. Sunari  DM KAD Sepsis
4. Tn. Subakin  AIHA
5. Ny. Sri Wahyuningsih  DM
6. Tn. Reman Suhartono  Tb paru DMT2
7. Ny. Sumi’a  PVC
8. Ny. Hindun  CKD HD
9. Ny. Astutik  Mitral prolapse + aorta stenosis
10. Tn. Nafik  GEA colic abdomen
 Patient’s Identity

• Name : Tn. Sunari

• Age : 50 years old
• Address : Kembangbahu, Lamongan
• Admission : August, 29th 2018 at 02.59 AM
 Anamnesis
Present History

Chief Complain Patient visited RSML’s ER with the chief complaint

shortness of breath since 1 day and become heavy 2
hours before went to ER. Shortness of breath not
Shortness getting better with position change. Patient also
complaint nausea and vomiting 2x contained food.
of breath Palpitatipn during activity denied. Woke up at
midnight because of shortness of breath denied.
There is no problem with defecation and urinate.
 Anamnesis
Past History of Illness
Patient hospitalized 2 months ago with
the same complaint. Patient was
Controlled DM. HT denied. Family History
There was no family history of kidney or
heart disorder.

Social History
Patient slept with 1 pillow
 Physical Exam
A
Vital Sign clear, gargling (-), snoring (-), speak fluently (+), potential
obstruction (-)
• BP : 159/89 mmHg
B
• Pulse : 126x/min spontan, RR 36x/min, ves / ves, rh -/-, wh -/-, SaO2 100% with
• Temp : 36.50 C O2 support

• RR : 36x/min C
DWR, CRT <2’, N 126x/min, BP 159/89 mmHg
D
GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E
Temp 36,5 0 C
 Physical Exam
General Status
• General condition : weak
• Awareness : compos mentis
• GCS : 456
• H/N : a-/i-/c-/d+
lymph node enlargement at neck (-)
JVP within normal limit
Edema facial -, Macula eritematous -
 Physical Exam
Thorax Abdomen
• Inspection • Inspection
• Symmetrical, retraction +/+ • flat, mass (-), collateral vein (-)
• Palpation • Auscultation
• Thrill (-), fremitus WNL • Meteorismus -, bowel sound WNL
• Percussion • Palpation
• Lungs: sonor / sonor • Not palpable hepar and spleen
• Cor: N • Percussion
• Auscultation • Tymphany
• Lungs: ves /ves, rh -/-, wh -/-
• Cor: S1 S2 single, murmur -, gallop -
 Physical Exam

Extremities
• Inspection
• Anemis (-), icteric (-), cyanosis (-), edema (-)
• Palpation
• DW Red, CRT <2’
 Clue and Cue
•Male, 50 years old
•Shortness of breath
•BP 159/89 mmHg
•Pulse 121 x/min
•Thorax retraction +/+
•DM history
 Planning Diagnosis
•DL
•GDA
•BGA
•SE
•Thorax photo
 Assesment
•Type 2 Diabtes Mellitus
 Laboratory Findings
• GDA 408 • cHCO3 3,1 • Basofil 2,4 (0-1)
• Keton 2,7 • Klorida 97,6 (98-107) • Eritrosit 4,67 (3,8-5,3)
• Kalium serum 5,6 (3,6-5,5) • iCa 1,14 (1,420-1,720) • Hb 14,6 (P 13-18 L 14-18)
• Natrium serum 128 (135- • PCO2 13,9 (35-45) • HCT 44,7 (L 40-54 P 35-47)
155) • pH 6,972 (7,35-7,45) • MCV 95,7 (87.00-100)
• Clorida serum 88 (70-108) • PO2 142,2 (80-100) • MCH 31.30(28.00-36.00)
• Urea 57 (10-50) • SO2 96 (75-99) • MCHC 32,70 (31.00-37.00)
• Serum creatinin 1,4 (P 0,7- • Leukosit 34,8 (4-11) • RDW 11 (10-16,5)
1,2 L 0,8-1,5)
• Neutropil 80,2 (49-67) • Trombosit 416 (150-450)
• tHb 13,4
• Limfosit 10,5 (25-33) • MPV 7 (5-10)
• Be -26,9
• Monosit 4,5 (3-7)
• Beecf -28,6
• Eosinophil 2,4 (1-2)
Radiological Finding
EKG
EKG
EKG
EKG
EKG
 Re-Assesment
•Diabetic Ketoacidosis
•Hyperglicemia
•Dyspnea
 Planning Therapy
• O2 NRM 10 lpm
• Catheter  residual 500 cc
• Inf. Asering loading 2000 cc, maintenance 20 tpm
• Novarapid 2 IU/jam
• Inj. Ceftriaxon 2x1gr
• Inj. Panloc 1x40 mg
PLANNING MONITORING
Planning Monitoring

•Vital Signs
•Patient’s complaint
•Adverse effect
 PLANNING EDUCATION
Planning Education

Explain to the patient and his family about the

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