Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
Juny 10th 2015
TEAM 3

Tn A. 22 YO
CC : Shortness of breathe
Findings
Shortness of breathe
GCS: E4V5M6, TD: 140/90, PR : 86x, T : 36,4oC, RR: 28x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : 5 - 2 cmH2O
THRORAX

: Intercostal movement simetric

Pal: Vocal fremitus simetric
Per: Sonor right = left
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1
and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold warm, CRT < 2, turgor
normal

Assesment

Therapy

Diabetic
Ketoacidosi
s severe on
DM type II

MM/
Ceftizoxime 2x1 gr IV
Omeprazole 1x10 mg PO
Domperidon 3x10 mg
Titrasi Novorapid
<100 : Novorapid stop -> Infus ganti
dextrose 5% / 8jam
100-150 : Novorapid stop
150 200 : drip turunkan 50% dari dosis
terakhir novorapid
200 240 : 1 unit
241 280 : 2 unit
281 320 : 3 unit
321 360 : 4 unit
361 400 : 5 unit
401 440 : 6 unit
>441 : 7 unit

Planning
Pro Hospitalized
Face Mask 8 LPM
Nasi Tim 1700 Kalori
IVFD :
-NaCL 0.9 % /4 jam
-Novorapid drip 3 unit / jam
Balance cairan ketat
Periksa GDS / jam
Periksa elektrolit dan AGD / 12
jam
Foto thorax

Subjective Data
Name
CM
TC
CC

: Tn . A, 22 years old
:
: Wednesday , June 10th 2015
: Shortness of breathe

Anamnesis
Main symptom
Additional symptom

: Shortness of breathe
:-

Patients present with shortness of breath.

complaints felt since 11 hours SMRs. patient also
had nausea and vomiting megeluhkan 10 times.
said patients have a history of high blood sugar.
patients also had 3 days ago do not defecate,
urinate but no complaints. Decreased appetite due
to nausea and vomiting
History of trauma (-) Astma (-) History of DM type II.

Past Medical History and Treatment

(-)

Family History

(-)
Social History
(-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 140/90 mmhg,
RR: 28/ minute,
T : 36,4C
Pulse : 86 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : 5 - 2 cmH2O

 Thorax
I

Abdomen.

: intercostal movement simetric

Pal: Vocal fremitus simetric
Per: Sonor right = left
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

I : flat
Aus : bowel sound (+) 4x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)

Extremity
-

Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal

Clinical Laboratory
Hematologi

Hemoglobin : 17,8 gr/dl

Leukosit : 13.2 rb/ul
Hematokrit : 52 %
Trombosit : 209 rb/ul
GDS : 365 mg/dl

Elektrolit
Natrium
Kalium
Clorida

128 mmol/L
5.3 mmol/L
102 mmol/L

Ureum Darah 38 mg/dl

Creatinin Darah
1.24 mg/dl

X-Ray

Assessment
Diabetic Ketoacidosis severe on DM type II

Therapy
MM/
Ceftizoxime 2x1 gr IV
Omeprazole 1x10 mg PO
Domperidon 3x10 mg

Titrasi Novorapid
<100 : Novorapid stop -> Infus ganti dextrose 5% / 8jam
100-150 : Novorapid stop
150 200 : drip turunkan 50% dari dosis terakhir novorapid
200 240 : 1 unit
241 280 : 2 unit
281 320 : 3 unit
321 360 : 4 unit
361 400 : 5 unit
401 440 : 6 unit
>441 : 7 unit

Planning
Pro Hospitalized
Face Mask 8 LPM
Nasi Tim 1700 Kalori
IVFD :
-NaCL 0.9 % /4 jam
-Novorapid drip 3 unit / jam
Balance cairan ketat
Periksa GDS / jam
Periksa elektrolit dan AGD / 12 jam
Foto thorax

Department of Internal
Medicine
Christian University of Indonesia

Thank You