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MORNING REPORT

October 7th , 2014

Coass in charge:

Putu Nina e!in"a #a$a

%a&i" Chan"ra

MO%ER'TOR : "r( Nur #a)su, #*(P%

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Mrs( #+1-o+.221. General weakness

1. 1 Nausea and vomiting1.2 Low intake

2. Chronic lung infection

2.1 Tb paru

2.2 Brokiektasis

. !neumonia hcap

". #ipokalemia".1 Low intake

".2 G$ loss

%. &'otemia pre renal

%.1 (olume depletion

). Trombositopenia

).1 !rimer).2 *ekunder

+. ,lkus decubitus

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#/MM'R O %'T' '#E

Mrs( #+1-o+.22

Chie co)*!ain: genera! 3ea$ness

!atient felt general weakness continousl- since 1 week ago. General

weakness would be increased if she do an- activit- and relieved if she

lied down on bed. *he felt fatigue in all of the bod- and /cekot0cekot

in her feet. *he would feel d-spneau if she walk % meter or more. *o

she prefer to sit down or lie down on the bed for long time. There was

no d-spneau in the night sleep and no need more than 1 pillow to sleep.Because of prolonged rest on the bed there are lesion on right bottom

and both of her elbow. $n addition she has been coughing for " months.

There is no sputum onl- dr- cough and she felt itch- in her throat. *he

felt decrease of appetite because of she felt bad with her tounge and

painful when swallowing. #er daughter said that she got weight loss 1kilogram for " months. *he onl- defecate once for this 2 weeks.

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#/MM'R O %'T' '#E

Mrs( #+1-o+.22

Me"ica! histor- : 2 months ago she was hospitali'ed at 3* Batu because

of she felt fatigue. The doctor diagnose her with disease in lung stomach andliver. The cough had been slightl- decrease and after 1 week she was

outpatient and she felt the same complaint again. *he felt decrease of

appetite fatigue and was hospitali'ed again in 3* Gondang Legi for 1 week.

she had been in the house for weeks before she was going to emergenc-

department of 3**&.

4amil- histor- 5 There is no histor- of the same s-mptom as hers in herfamil- or neighborhood. *he does not have histor- of 67 #TN asthma

and allerg- of food or medication. *he also has not histor- for smoking and

drinking alcohol. *he drinks /8amu once a week and like to eat vegetable

*ocial histor- 5 *he is a cane farmers. *he alwa-s go to cane fields ever-da-

e9cept *unda- from ) am untul 12 pm. #er husband had been passed awa-

-ears ago and now she is living with her children. *he has 2 daughters and 2

sons.

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P#IC'5 E6'MIN'TIONBP = 160/100 mmHg PR = 88bpm, strong,

regulerRR = 18 tpm Tax : 36.7 !

General appearance looked moderately ill,Bradipsiki, uremic foetor(+)

GCS 456 Looks normoei!"t

#ead $nemic % &cteric % 'S isus * 6-' Su.con/untial

"aemorr"a!e (+)0eck 123 + cm#' -7

8"ora9: Cor: &nisi.le and palpa.le at &CS 2 ;CL (S)#; < SL e9traL#; < &ctusS S sin!le murmur(%) !allop(%)

Lun!: Simetric, S= > S P s s ' & & Rh .h s s b& & 88

s s b& & 8

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911++2014;

5ab 910>+u5; Natriu) 12= 1>14 ))o!+5

ae)og!obine 12,70 1>,417,7g+"!

?a!iu) 4(7 >,,0 ))o!+5

MC< => =0@> A Ch!ori"a 10 @=10 ))o!+5

MC 2@(0 27>1 *g R# 14= B 200 )g+"!

PC< >(0 4047 '!bu)in >(@2 >,, g+"!

Tro)boc-te 4> 142424910>+u5;

/reu) 74(@0 100 )g+"!

%iD(count :Eos+bas+neu+!i)+)on

1(+0(2+=2(1+10(>+(4

04+01+17+2>>+2

Creatinine

eGR

2(@

2=(=1

B 1(2 )g+"5

#GOT 21 040 /+5

#GPT 1@ 041/+5 PPT'PTT

10(702=(0

?( 11(111(?( 2=(@>0(

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CXR

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C6R Mei 11th201>

&! position as-mmetric enough :( enough inspiration

Trachea in the middle*oft tissue and bone normal

!hrenico costalis angle de9tra and sinistra are sharp

#emidiaphragma de9tra and sinistra are dome shape

Lung5 B(N normal

Cor 5 site normal CT35 %;.

Conclusion 5

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ECG

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ECG

#inus Tachicar"ia, eart rate 110 b*)

ronta! 'is : nor)a!

oriFonta! 'is : C!oc$ 3ise rotation

PR inter&a! : 0,20

HR# co)*!e : 0(1

HT inter&a! : 0(>2

Conc!usion : #inus tach-car"ia 110+)inute

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C/E 'N%C5/E

P5 I% P% PT P)o

e)a!e+ 1 -(o(General weaknesscontinousl- since 1week ago$t would beincreased if she doan- activit- andrelieved if she lieddown on bed

P( 10+@0PR( @2RT: re""isheca! 8, Mass98; 12 c)5ab:b 12(70

MC< =>MC 2@(0

1( e)atocheFia

2( %-s*e**sias-n"ro

)e

1(1 5o3er GI!ee"ing1(1(1e)orrhoi"sinterna1(1(2%i&erticu!osis1(1(>Ma!ignanc-

2(1 Gastritis2(2 P/%

Co!onosco*-/#G'b"o)en5,OT

=2 20" lpm NC$(46 NaCl >; dpm$n8.&sam trane9amat 9% mg?$(@

$n8.=mepra'oe 19" mg ?$(@$f not availableranitidin 29 %mg i.v

#ub(co)*!ain!ee"ingCC

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C/E 'N% C5/E P5 I% P% PT P)o

Ma!e + 47 -oistor- o-*ertension 98;istor- os)o$ing 98;

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C/E 'N% C5/E P5 I% P% PT P)o

Ma!e + 47 -o%-suriaPo!a$isuriaistor- o e&er98;

5ab :5eu$oc-te 1=,4/5 :Nitrit 98;5eu$oc-te 82

acteria1>11(110>

".Leukositosis

(1Inection(1(1 /TI(2Reacti&e

$n8.Ciproflo9acin 292 mg?$(@

#ub(

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Than$ -ou

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69 kolonoskopi ,*G &bdomen konsul ruangan neuro ,L Lipid profile &s.,rat

BG& 4L 4=BT

Terapi 5

=2 2 lpm NC

$(46 NaCl >; 2 tpm

$nsert NGTGLA 8am1 9 bersih start diet cair )92 cc

$n8.=mepra'oe 19" mg ?$(@

$n8.&sam trane9amat 9% mg ?$(@

$n8.Ciproflo9acin 292 mg ?$(@

Balance nol

!=A

&mlodipin 19% mg ?%00D

7onitoring 5*ub8(*!erdarahan !rod ,rine 6L

:$E 5 :ondisi rencana terapi rencana diagnosis