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MORNING REPORT
October 12nd 2014
TEAM 3
Assessment
LAB FINDING:
Complete Perifer Blood :
Hb : 7,2 gr/dl Leu : 15.800/ul ; Ht : 20,6%
Tro : 336.000/ul, ureum: 197, creatinine : 13,17
Therapy
Pro Hospitelize
IVFD : Inj plug
Diit : smooth with 40gr
protein
Mm/
Bicnat 3x1
Ceftriaxon 1x2 gram
CaCo3 3x1
Furosemide 2x1amp
Ranitidine 2x1amp
Pro Renal 3x2
Check balance
Planning
Check balance
Check blood gas
analysis and electrolite
Subjective Data
Name
Address
TC
CC
: Mr. M
: Jakarta
: Sunday/12nd October 2014
: Breathless
Anamnesis
Main symptom
Additional symptom
: Breathless
: Cough, nausea
56 years old male patient came to hospital with complaint of breathless since
three days before admission. The complaint came suddenly and continously. The pain
wasnt diffuse to arm and spine. Pain felt worsen while lying down, and better when
sitting. The other complaints he had were cough and nausea (since 3 days before
admission).
Patient has no history of hypertension, diabetes mellitus. The patient denied
any cough. The patient denied any complaints on the urination and defecation but
the patient consume medication for kidney since 4 years ago. The patient denied
history of allergy.
Objective Data
LOC
Appearance
BP
PR
RR
Temp
EYE
Neck
: E4V5M6 ; Composmentis
: moderate ill
: 150/70 mmHg
: 101 x/min (adequate,regular)
: 30 x/min
: 360C
: anemic conjungtiva -/- ; ict -/: lymph nodes did not enlarged, venous distention +
THORAX
:
Heart
Ins : IC not visible
Pal : IC palpable
Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)
Objective Data
PULMO
Insp
Pal
Perc
Ausc
ABDOMEN
Insp
Ausc
Pal
Perc
BACK
Perc
EXTREMITIES
Edema (-); warm (+); capp. Refill <2 seconds
Clinical Laboratory
Hb
Ht
Leukosit
Trombosit
Ureum
Creatinin
: 7,2 gr/dl
: 20,6%
: 15.800/ul
: 336.000/ul
: 197
: 13,17
Assessment
Therapy
Pro Hospitalized
IVFD : Inj. plug
Diit : Smooth, 4gr protein
Mm/
- Furosemide 2x1amp
- Ceftriaxon 1x2gr
- Ranitidine 2x1amp
- CaCo3 3x1
- Pro Renal 3x2 tab
- Bicnat 3x1 tab
Planning
Check balance
Check blood gas analysis and electrolite
Thank You