Professional Documents
Culture Documents
Morning Report
History of past illness: He suffered from colon tumor and had been tumor resection 10th years ago. She was admitted in RSSA this March 2013 because of Shortness of breath and leg swelling. She had Hypertension known since march 2013. History of diabetes and allergic unremarkable.
Family history: Her mother and sister was diabetes . She is a pensioners. She had 4 children, one of her son was die because of motor accident. Reviem of systems Unremarkable
Physical Examination BP= 90/palpation mmHg PR= 90 bpm irregular RR =10 tpm on NRBM 12 Lpm saturation 95% GCS : 1 1 1 Icteric sclerae (-) Pupil isokor D/S 2 mm Neck stiffness (-) Ax. Temp.= 36.3 0C
General App.: looked severely ill Head Neck Thorax Anemic conjunctiva (-)
JVP : R + 0 cm H2O; 300, Cor Ictus invisible, palpable at ICS VI, MCL S RHM SL D LHM ictus S1, S2 single, murmur Pulmo Symmetric; SF D=S; S| S V | V Rh +|+ Wh - | S| S V | V +|+ -| S| S V |V +|+ -|soefl, BS (decreased), Liver span 8 cm, traubes space dull , Oedem-, cold acral, --
LABORATORY FINDINGS LAB RESULT Leukocyte 18.890 Hemoglobine MCV MCH PCV Thrombocyte 14,4 77,7 26,6 42,10 367.000
NORMAL VALUE 136-145 mmol/l 3.5-5.0 mmol/L 98-106 mmol/L <1 mg/dL
mg/dL
11,0 s 26,2 s
<200 mg/dl
Ureum
16,6 48,5
Result 7,32 7,45 33,1 30,6 196,7117,4 17,2 21,2 99,6 98,8 % - 9,0 -3,1
Normal Value 7,35 7,45 35 45 mmHg 80 100 mmHg 21 28 mmol/L (-3) (+3) mmol/L
Echocardiography: Consentric LVH with decreased in RV systolic accompanied with mild AR and mild PH Septal hypokinetic at middle and basal also middle anterior Conclusion : HHD and ischemic heart disease
CXR : AP position, asymmetric, enough inspiration, KV enough, trachea in the middle with ETT inserted, bone normal and soft tissue normal , Phrenicocostalis angle D and S Sharp, Hemidiaphragm D/S domeshaped, Pulmo: BVP normal, cephalisasi (-), infiltrate (+) Cor: aortic elongation, cardiac waist -, CTR 62%
Conclusion : cardiomegaly
ECG at RSSA: Irregularly irregular rhytm, HR 50 150 bpm, mean HR 100 bpm No P wave QRS : 0,08 s QT interval : 0,28 s FA : cannot be evaluate HA : normal Q wave at V1-V2, Strain pattern at II, AVF, V4, V5, V6 Conclusion : atrial Fibrillation NVR + OMI anterior + LVH
Problem list Female, 71yo 1. 1. Shock Decrease of condition conciousness 2. GCS 111 BP 90/mmHg HR: 90bpm Cold acral Anuria Clue and cue Planning Therapy Monitoring O2 jacksen rees 12 S Lpm VS every 15 Urine Liquid Diet 1500 production Kcal/day--NGT SE every 4 hr BGA every 6 NE 0,05-2 hr mcg/KgBW/Minutes Dobutamin 520mcg/kgbw/min Ranitidine 2x50 mg IV Treat underlying disease Consult to neurologist
Female 71 yo Decrease of conciousness GCS 111 History of CVA few month ago Head Ctscan ICH Ureum 174 Creatinin 5.4 Female 71 yo Decrease of conciousness GCS 111 RR 10tpm 12lpm with jacksen reese Ureum 174 Creatinin 5.4 Leucocyte
2. decreased of conciousnes s
GCS
3. Septic conditio n
S, VS
5 18.890 CXR: pneumonia Female 71 yo Ureum 174 Creatinin 5.4 BUN/Cr: 14.9 CG-GFR: 7.5ml/min Female 71 yo BP 90/ECG: AF NVR+OMI
4. Azotem ia renal
Vs,
5. HF st C FC IV
NT proBNP
S, VS ECG
albumin
7. AF NVR
S, VS ECG monitoring
Explained recent condition, probable causes of disease, Explained recent condition, probable causes of disease