Morpot Kelompok 3

Mr.
Hari, 63 years old
CM :
Jakarta
TC : Friday
CC : hematemesis
Date : 26-8-16
Findings
Hematemesis 3 times. Pure
blood.
- Illness histories : CKD on HD since
5 years ago. Gastritis
- Phys Ex :
LOC :
GCS : E4 V5 M6, compos mentis
BP : 70/40 mmHG
PR : 70x/ mnt
RR : 19x/mnt
Temp : 36.70C
Head and Eye :
Normocephaly
Anemic conjunctiva +/+
Icteric sclera +/+
Thorax :
Ins : movement of chest wall
symmetric
Pal : Vocal fremitus symmetric
Per : Sonor/sonor
Aus : basic breath sound vesicular
,
Ronkhi -/-, wheezing -/-, heart
sound I & II regular, murmur (-)
gallop (-)
Assessment
1 Anemia
2 Hemateme
sis Melena
3 CKD on HD
Therapy
1 Mm :
Vit K 1 amp
Tranexamic Acid 500
mg
Omeprazole drip
IVFD :
III RL/24 h
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 4.5 g/dL
L: 7.300 L
HT: 13.9%
T: 112.000 uL
3. Electrolyte results :
Na : 142
K : 3.9
Cl : 106
Abdomen :
Ins : stomach looks flat
Aus : bowel sound 6 times/mnt
Per : Hyper-tymphany, percussion
pain (-)
Pal : Supple, Pressure pain (-)
Ext : warm, capillary refill <2
edema (-)
Skin : turgor decrease
Mrs. Theo, 52 years old
CM :
Jakarta
TC : Sunday
CC : Nausea
Date : 14-8-16
Findings
- Nausea since 2 months,
out of breathe, chest
pain, anorexia,
weakness, weight loss,
headache
- Illness histories :
Hepatitis C, Gaster Polip
- Phys Ex :
LOC :
GCS : E4 V5 M6, compos
mentis
BP : 140/70 mmHG
PR : 80x/ mnt
RR : 22x/mnt
Temp : 360C
Head and Eye :
Normocephaly
Anemic conjunctiva -/Icteric sclera -/Thorax :
Ins : movement of chest
Assessment
1. Difficult
intake
2. Hepatitis C
3. Post
Colonoscopy
Therapy
1. Mm :
Omeprazole 2x1
Sucralfat 3x1 c
B comp vit 2x1
IVFD :
II RL/24 h
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 13.8 g/dL
L: 6.600 L
HT: 41.9%
T: 222.000 uL
wall symmetric
Pal : Vocal fremitus
symmetric
Per : Sonor/sonor
Aus : basic breath sound
vesicular ,
Ronkhi -/-, wheezing -/-,
heart sound I & II regular,
murmur (-) gallop (-)
Abdomen :
Aus : bowel sound 8
times/mnt
Per : Tymphany,
percussion pain (-)
Pal : Supple, Pressure
pain (+) on epigastric
region, hepatomegaly
Ext : warm, capillary refill
<2 edema
Ext sup dex(-) et sin (-)
Skin : no abnormal
findings
Mr. Hery, 50 years old
CM :
Jakarta
TC : Sunday
CC : Out of breathe
Date : 14-8-16
Findings
- Out of breathe, bloated, tea-like
urine
- Illness histories : Liver cirrhosis
- Phys Ex :
LOC :
BP : 120/60 mmHG
PR : 82x/ mnt
RR : 30x/mnt
Temp : 36.40C
Head and Eye :
Normocephaly
symmetric
Per : Sonor/sonor
Assessment
1. Chronic
hepatitis
2. Ascites
Therapy
Mm :
Omeprazole 2x40
Sucralfat 3x1 c
Propanolol 1x1
HP Pro 3x1
Planning
1. Pro Hospitalized
2. Diet : soft food
3. H2TL results :
HB: 12.8 g/dL
L: 6.700 L
HT: 39.7%
T: 95.000 uL
4. Thorax photo

,
gallop (-)
Abdomen :
Per : Hypertymphany, percussion
pain (+)
Pal : Supple, Pressure pain (+),
hepatomegaly below 3 fingers on
arcus costae
edema
Skin : no abnormal findings
Mr. Jusman
CM :
Jakarta
TC : Sunday
CC : Weakness
Date : 14-8-16
Findings
- Weakness since 2 days ago, lost
appetite,
- Illness histories : - Phys Ex :
LOC :
BP : 120/80 mmHG
PR : 60x/ mnt
RR : 20x/mnt
Temp : 370C
Head and Eye :
Normocephaly
Assessment
1. Difficult
intake
2. Hypokalem
ia
Therapy
1. Mm :
Sanmol 3x1
Ranitidine 2x1
B.comp vit 1x1
IVFD :
I RL/24 h
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 15.7 g/dL
L: 9.200 L
HT: 48.1%
T: 228.000 uL
3. Electrolyte result :
Na : 138
K : 3.4
Cl : 100
Blood Glucose : 101

symmetric
Per : Sonor/sonor
,
gallop (-)
Abdomen :
Per : Tymphany, percussion pain
(-)
edema
Mr. Heryanto
CM :
Jakarta
TC : Sunday
CC : Diarrhea
Date : 14-8-16
Findings
- Diarrhea, nausea, vomiting,
shivering
LOC :
BP : 120/80 mmHG
PR : 68x/ mnt
RR : 18x/mnt
Temp : 36.40C
Head and Eye :
Normocephaly
Assessment
1. Acute
Gastroenteritis
Therapy
1. Mm :
Ceftizoxime
2x1 gr
Domperidone
3x10
Omeprazole
1x40
Antacids 3x1
c
IVFD :
IV RL/24 h
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 17.7 g/dL
L: 18.200 L
HT: 54.5%
T: 204.000 uL

symmetric
Per : Sonor/sonor
,
gallop (-)
Abdomen :
(-)
edema
Mr. Suryadi
CM :
Jakarta
TC : Sunday
CC : Nausea
Date : 14-8-16
Findings
- Nausea, vomiting, epigastric pain,
diarrhea
LOC :
BP : 110/80 mmHG
PR : 70x/ mnt
Assessment
1. Acute
Gastroenteritis
Therapy
1. Mm :
Ceftizoxime
2x1 gr
Domperidone
3x10
Omeprazole
1x40
Antacids 3x1c
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 16.2 g/dL
L: 18.500 L
HT: 50%
T: 227.000 uL
RR : 20x/mnt
Temp : 36.20C
Head and Eye :
Normocephaly
symmetric
Per : Sonor/sonor
,
gallop (-)
Abdomen :
(-)
edema
IVFD :
RL/24 h
Mr. John
CM :
Jakarta
TC : Sunday
CC : Out of breathe
Date : 14-8-16
Findings
- Out of breathe, nausea,
coughing
- Illness histories : CKD on HD,
Type 2 DM
Assessment
1. Bronchopneu
monia
2. CKD on HD
Therapy
1. Mm :
Furosemide 2x1
amp
Ceftizoxime 2x1 gr
Planning
1. Pro Hospitalized
2. H2TL results :
HB: 9.1 g/dL
L: 16.800 L
Phys Ex :
LOC :
BP : 180/110 mmHG
PR : 110x/ mnt
RR : 38x/mnt
Temp : 36.30C
Head and Eye :
Normocephaly
symmetric
Per : Sonor/sonor
Aus : basic breath sound
vesicular ,
Ronchi +/-, wheezing -/-, heart
gallop (+)
Abdomen :
(-)
edema
Ext sup dex(+) et sin (+), ext inf
dex(+) et sin (+)
KSR 2x1
Omeprazole 1x40
IVFD :
Inject plug
HT: 27.2%
T: 254.000 uL
3. Electrolyte results :
Na : 137
K : 2.8
Cl : 104
Blood glucose : 123

Morpot Kelompok 3

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Morpot Kelompok 3

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Mr.

Hari, 63 years old

Mrs. Theo, 52 years old

Mr. Hery, 50 years old

Aus : basic breath sound vesicular

Ins : movement of chest wall

Anemic conjunctiva -/Icteric sclera -/Thorax :

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