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8/18/2019 Morep Interna 12 September
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EMERGENCY ROOM
MORNING REPORTINTERNA DEPARTMENT
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IDENTITY
• Name : Mrs. Kastini
• Age : 50 y.o
• Se : !ema"e
• A##ress : $an#ean RT% R&' K"oto( P")m*ang T)+an
• Date o, eamination : A)g)st %-t/ %0'5
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ANAMNESIS
Cie, om*"aint
Sortness o, +reat
Present I""ness 1istory
Patient 2as re,ere# ,rom M)ama#iya 3a+at 1os*ita" 2it ie,
om*"aint sort o, +reatness sine 5 #ays ago. Patient ,e"t sort o,
+reatness ontino)s"y an# get 2orse i, se #i# an ati4ity/ "ying
an# 2a"(ing ,or a+o)t '0 m. Patient )s)a""y s"ee* 2it one *i""o2/
se o,ten 2a(e )* in te mi##"e o, te nigt ,or mition. Na)seo)s
67 an# 4omit 67. 8omitting ,or a+o)t 9 times an# ontains ,oo#s.
Se a"so ,e"t itiness +ot in er "egs an# arms. Co)g 7. Cest
*ain . Pain in er stoma 67/ ,e"t "i(e sta++e#. Pain 2en mition.
De,eation 2itin norma" "ine. Derease in a*etite.
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• Past I""ness 1istory : 1i*ertension )nontro""e#/Dia+etes Me""it)s ,or 5 years )se# ins)"in +)t#i#n;t ro)tine ontro""e# in mantri. 1emo#ia"isa
istory 7.• !ami"y I""ness 1istory :
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PRIMARY Smnt/ ()sma)" +reating/4es>4es/ R6>6/ 2>/ SaO% '00? 2it NRM O%'0"*m
• C: a(ra" Co"#/ Dry/ Pa"e/ CRT @%/ PR: 9>mnt/ 3P:'5>'00 mm1g
• D: GCS 9B5/ "atera"isation / Ro)n# P)*i" iso(or 9mm>9mm/ $R6>6
• E: tem* 9-C/ )rine o)t*)t '00
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SECONDARY SN : a6>i>>#6/
• Cest : sim>sim/ ret6>ret6
•
$)ng : 4es>4es R6>6 2>• 1eart : S' S% sing"e/ m)rm)r >/
ga""o* >
• A+#omen : soe*e"/ met / +o2e" so)n# 6
norma"/ 1>$ )n*a"*a+"e/ E*igastri *ain 67• Etremity : ai >/ CDP/ *reti+ia e#ema
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P$ANNING DIAGNOSIS
• D$• SE• R!T• $!T• Tora *oto• ECG• 3"oo# Gas Ana"ysis•
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$A3ORATORY !INDING
• GDA : 9-' mg>#"• Eritroyte : '.5• 1ematorit : '
?•
1+ : 5. mg>#"• $im*oyte: B.5• 3aso*i": %.B• Eosino*i" : '.• Monoyte : '.-•
$e)oyte :'.000• Ne)tro*y": .• Trom+oyte :
--'.000
• C"ori#e : '0• Natri)m : 'B%• (a"i)m -.0•
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T1ORAF AP TID
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ECG
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C$
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ASSESMENT
1y*ertension Emergeny DM ty*e II SIRS
Anemia 1y*er(a"emia Asi#osis meta+o"i A$O CKD
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P$ANNING T1ERAP1Y
• 1a", sitting *osition• O% mas( '0 "*m• DK • I8!D PH "i,e"ine• In !)rosemi# % am* resi#) J %00 / 3P '9B>'00 J
,)rosemi# 9' am*• In S)"*eraone %' gr• In Ca G")(onas '0 +o")s DB06%I< ins)"in/ 9 inter4a"
one o)r e( Ka"i)m 6 Ran#om 3"oo# G")ose• RCI 9B I< i, Ran#om 3"oo# G")ose J %50 *ost (a"i)m
orretion• Pro trans,)sion '(o",>#ay *reme# ,)rosemi# ' am*• Cons)"t: Internist/ Anestesia S*eia"ist
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PROGNOSIS
• D)+ia a# ma"am
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Patient om*"iane
8ita" sign
)rination *ro#)tion
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E*"ain to te *atient;s ,ami"y a+o)t te#iagnosis/ etio"ogy/ inter4ention o, tera*y/om*"iation/ an# *rognosis.