MORNING REPORT

T I M JAG A : DM FA R I ZAN, DM M E YTA , DM N A N DA , DM DI A N

P E MBI MBI NG
d r. N a ni Za i t u n , S p . PD
Identitas pasien
Nama : Ny. S
Umur : 60 tahun
Agama : Islam
Suku : Banjar
Status : Menikah
Pekerjaan : ibu rumah tangga
Alamat : Jl. Kelayan

MRS : 10 Juli 2019

Anamnesis
Chief Complain: Short of Breath
-Shortness of breath since 1 month before admision getting worse in 7
days. SOB come all time, when patient get activity and rest. Because short
of breath, the patient avoid the activity. Patient from the last year, sleep
using more than one pillow and sometimes sleep in a stting position.
-Cough since 1 month, at first, coughing is unproductive and in the last 7
days become productive. Phlegm changes from white to yellowish, the
patient said he never coughed up blood. Cough apper most often at night,
making the patient wake up during sleep.
-The patient does not complain of fever, sore throat, and weight loss, but,
in last week, there was pain in the body, and sometimes headache
History of previous disease
Patient routinely get hemodialysis since the last 1 year due to chronic kidney disease on Tuesday
and Friday. On last week the patient drop out from HD.
Hypertension since the last 1 year, when patients are diagnosed with chronic kidney disease.
The patient had received pulmonary TB treatment from radiologist in banjarmasin 6 month ago
History of family disease
HT (-) DM (-) TB (-) OAT (-) Asthma (-) heart disease (-) renal disease (-)
History of contact with TB patient denied
History using drug : Herbal
Occupation : jobless
 PHYSICAL BP = 110/70 mmHg HR= 70 Bpm RR= 36 x/min T=36.8◦C
EXAMINATION BW= 50 Kg SpO2: 99% oxygen
BH= 165 cm 4lpm
Keadaan umum : tampak sakit ringan GCS E4V5M6 compos mentis
Mata dan kulit -Congjungtiva: anemic Turgor cepat kembali < 1 detik
(+/+) Kulit hipopigmentasi (-)
- Sklera icteric (-/-) Rash (-) kering (-) ptekie (-)

Leher JVP R+7 cmH20 at 30◦; no enlargement lymphonodes

Thorax: Ictus cordis invisible
Cor Ictur cordis palpable at ICS V AXL ANT Sinistra
S1, S2 tunggal, Murmur (-)

Nafas: Simetris (+/+) ,

Palpasi: fremitus vocal normal
Perkusi : S S
S S ; Aus: Rh ++ Wh - -
S S ++ --
++ --
Suara nafas vesicular (+/+)
Abdomen Inspeksi: Striae (–), scar (-)
Auskultasi: BU(+)
Palpasi: Hepar tidak teraba, lien teraba (schafner ii)
Nyeri tekan: - - -

- - -

- - -
Perkusi: Shifting dullnes (-), Undulasi(-), timpani
Nyeri ketok ginjal (-/-)

Ekstremitas Akral Hangat + + Edem - -

++ - -
Kekuatan +5 +5
+5 +5
 LAB RESULT 10/7/2019

Hematologi Lengkap Result Reference value

hemoglobin 9.1 12.00 – 16.00
Eritrosit 3.81 4.5 - 6
Leukosit 7.2 5- 10
Hematokrit 28.2 38-52
Trombosit 152 50-450
MCH 74 26-32
MCV 23.9 82-92
MCHC 32.3 31-36
Hematologi Lengkap Result Reference value
Basofil% 0.4 0.0-1.0
Eosinofil% 0.3 1.0-3.0
Gran% 61.9 50- 81
Limfosit% 11.9 20.0-40.0
Monosit% 9.3 2.0-8.0
Basofil# 0.03 <1.00
Eosinofil# 0.02 <3.00
Gran# 4.05 2.5-7.00
Limfosit# 0.86 1.25-4.00
Monosit# 0.67 0.30-1.00
 Result Reference value
BSN 118 <200
Ureum 227 136-145
Kreatinin 15,48 0.72-1.25
Natrium 146 136-145
Kalium 4.6 3.5-5.1
Chlorida 106 98-107
- densitas normal
- deviasi trakea (-)
- infiltrat (-)
- CTR 70%
- sudut costophrenicus tajam
- sudut cardiophrenicus tajam
- Irama sinus, reguler
- 88 x/menit
- Aksis normal
- Terdapat gelombang
Q patalogis di
sadapan V4, V5, V6
 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

Ny. S 60 tahun 1. Epigastric 1.1 OMI Cek ulang - Aspirin 1x75 mg Monitoring Edukasi
Pasien datang dengan pain+Q patalogis 1.2 LBBB EKG - Omeprazole 1x40 mg TTV/24 jam penyakit, bed
keluhan nyeri ulu hati yang sadapan V$, V5, 1.3 Gastritis acute rest,
dialami kemarin jam 9 V6
malam. Nyeri dirasakan
menjalar ke punggung
belakang dan bahu kiri
sehingga membuat pasien
berkeringat dingin dan
sesak napas. Nyeri
dirasakan seperti ditusuk.
meminum promag tetapi
keluhan tidak berkurang.
Pasien belakangan ini tidak
kuat berjalan jauh
Terdapat gelombang Q
patalogis di sadapan V4,
V5, V6.
Peningkatan CKMB
CTR 70%
 CUE AND CLUE Problem List Idx PDx PTx Pmo Ped
Ny. S 60 th di diagnosis 1.Hiperglikemia 1.1 DM tipe 2 - Cek GDP - Metformin 2x500 Cek Edukasi
diabetes melitus 3 tahun - Cek GDP+GD2JPP penyakit, bed
lalu dan tidak teratur juga GD2JPP rest, Kurangi
untuk meminum obatnya. konsumsi
GDS : 225 Gula

Ny. S 60 th mengaku sudah 3 1. Hipertensi stg II - Amlodipin 1x10 mg Monitoring Edukasi

tahun menderita hipertensi TTV/24 jam penyakit, bed
tidak minum obat secara rest, kurangi
teratur untuk konsumsi
hipertensinya. garam.
140/80 mmHg
Thank You