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  • Morning Report Amel

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    Anonymous VEUa5p1I
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    This document provides a morning report on a 66-year-old male patient admitted to the hospital with coughing up blood. The patient has a history of uncontrolled diabetes, hypertension, chronic kidney disease, and is on routine hemodialysis twice per week. Physical examination findings include tachycardia, decreased breath sounds on the left side, and edema. Laboratory tests show kidney dysfunction with elevated creatinine and low hemoglobin. A chest x-ray found left pleural effusion and enlarged heart. The assessment is chronic kidney disease with left pleural effusion. The treatment plan includes oxygen, IV fluids, antibiotics, antacids, and consultation with an internist.

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    This document provides a morning report on a 66-year-old male patient admitted to the hospital with coughing up blood. The patient has a history of uncontrolled diabetes, hypertension, chronic kidney disease, and is on routine hemodialysis twice per week. Physical examination findings include tachycardia, decreased breath sounds on the left side, and edema. Laboratory tests show kidney dysfunction with elevated creatinine and low hemoglobin. A chest x-ray found left pleural effusion and enlarged heart. The assessment is chronic kidney disease with left pleural effusion. The treatment plan includes oxygen, IV fluids, antibiotics, antacids, and consultation with an internist.

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    16 views20 pages

    Morning Report Amel

    Uploaded by

    Anonymous VEUa5p1I
    This document provides a morning report on a 66-year-old male patient admitted to the hospital with coughing up blood. The patient has a history of uncontrolled diabetes, hypertension, chronic kidney disease, and is on routine hemodialysis twice per week. Physical examination findings include tachycardia, decreased breath sounds on the left side, and edema. Laboratory tests show kidney dysfunction with elevated creatinine and low hemoglobin. A chest x-ray found left pleural effusion and enlarged heart. The assessment is chronic kidney disease with left pleural effusion. The treatment plan includes oxygen, IV fluids, antibiotics, antacids, and consultation with an internist.

    Copyright:

    © All Rights Reserved
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    of 20

    Morning Report

    Departement of Internist (J-30)


    Amalia Ghanita Herdiana (201810401011065)
    Identity
     Name : Mr. K
     Age : 66 years old
     Adress : Jl Pemuda No 78 RT 4 RW 1 Brondong
    Lamongan
     Admission : August 7 th, 2018
    Summary Of Database
     Chief of Complaint : Blood cough
    Present history
     Patient complained coughing blood with blackish colour and
    clotted, coughing blood once, about as much as palm size.
    Nausea (-), vomiting (-)
    Past history of illness
    • uncontrolled Diabetes Mellitus (+) and hypertension (+),
    CKD (+), have hospitalyzed 5 months ago, HD routine at
    Petro twice/ week Tuesday and Thursday
    Family History

    •-
    Social History
    • Infrequently smoke and drink coffee. Drink 2-3 small
    cups/day and eat twice/day with little rice, never drink cola,
    energetic drinks, soda
    Vital Signs
    Blood Pressure
    109/81 mmHg
     Heart Rate
    90x/min
    Temperature
    37 C
    Respiratory rate
    26 x/min
    Primary Survey
    A : Clear gargling (-), snoring (-), Speak flequently (+),
    potencial obstruction (-)
    B : Spontan 22x/min
    C : Acral warm, dry, red. CRT<2s
    D : GCS 456, lateralisasi (-), PBI 3mm/3 mm, RC +/+
    E : Temperature 37 C
    Secondary Survey
     Awareness : Compos mentis
     GCS : 456
     Head/neck : a (+)/i (+)/c (-)/d (-)
    Thorax
     Inspection
    Symmetrical, retraction (-)
     Palpation
    Thrill (-), lifting (+)
     Percussion
    Lungs : sonor/sonor
    Cor : Normal
     Auscultation
    Lungs : ves/ves, rh -/-, wh -/-
    Cor : S1/S2 single, murmur -, gallop -
    Abdomen
     Inspection
    tenderness (-), ascites (+)
     Auscultation
    Bowel sound N
     Palpation
    Pain (-)
    Liver and spleen not palpable, ballotemen (+)
     Percussion
    Tymphany
    Extremity
     warm, dry, red, pitting oedem (-)
    Assesment
     Chronic kidney disease
    Planning Diagnose
     DL
     ECG
     Serum electrolyte
     GDA
     Creatinin serum
     Thorax PA
     Anti HCV
     HBsAg
    Laboratory
    Metode 1 : Non reactive Monosit : 8,6 (3,0-7,0)
    Hbs Ag : Negative Eosinophil : 1,9 (N 1-2)
    Anti HCV : positive Eritrosit : 3.33 ( N 3,8-5,3
    GDA : 118 mg/dl juta/mm3)
    Kalium serum : 3,7 (N 3,6-5,5) Hb : 9,0 ( N 14-18)
    Natrium serum : 138 ( N 135-155) Hct : 27,2 ( N 40-54)
    Chloride serum : 101 ( N 70-108) MCV, MCH MCHC, RDW dBN
    Urea : 88 ( N 15-43) Trombosit : 140000 (150000-
    450000
    Serum Creatinin : 6,4 ( N L
    0,8-1,5) MPV : 5 (N 5-10)
    Leukosit : 3,6 ( N 4,0-11) LED 1: 52
    Neutrophil : 62,9 (49-67) LED 2 : 76
    Limphosit : 22,6 (25-33)
    Thorax PA
     Cor besar dan berbentuk normal
     Pulmo tak tampak fibroinfiltrat
    Kedua sinus costophrenicus kanan tajam, kiri tumpul,
    Susp Efusi Pleura Sinistra
    ECG
    Interpretations : Tachycardia >100 bpm, Short PR
    Interval, Low Voltage Limb Lead
    Re-Assessment
     CKD with left pleural effusion
    Therapy
     02 nasal 4lpm
     Inf PZ lifeline
     Inj Antrhain 3x1 gr
     Inj Ranitidin 2x50 mg
     Consultation to chief internist
    JAZAKUMULLAH KHAIR… 

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