morep interna 12 september

8/18/2019 Morep Interna 12 September

1/16

EMERGENCY ROOM

MORNING REPORTINTERNA DEPARTMENT


2/16

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


3/16

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.


4/16

• 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 :


5/16

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


6/16

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


7/16

P$ANNING DIAGNOSIS

• D$• SE• R!T• $!T• Tora *oto• ECG• 3"oo# Gas Ana"ysis•


8/16

$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•


9/16

T1ORAF AP TID


10/16

ECG


11/16

C$


12/16

ASSESMENT

1y*ertension Emergeny DM ty*e II SIRS

Anemia 1y*er(a"emia Asi#osis meta+o"i A$O CKD


13/16

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


14/16

PROGNOSIS

• D)+ia a# ma"am


15/16

Patient om*"iane

8ita" sign

)rination *ro#)tion


16/16

E*"ain to te *atient;s ,ami"y a+o)t te#iagnosis/ etio"ogy/ inter4ention o, tera*y/om*"iation/ an# *rognosis.

morep interna 12 september

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