cc dr.ty kad

8/9/2019 cc dr.ty KAD

1/16

MORNING REPORT JULY 21

ST

2014


2/16

PATIENT IDENTITY1

Name : Mr. J

Age : 42 yo

Address : solo

Adimmted : july 21st, 2014

MR : 01191137

Ward : Melati 1 2!


3/16

ANAMNESIS2"#ie$ %om&lai' : %o's%ious'ess

(rese't )l'ess :

*i'%e 1 #our +e$ore admissio' &atie't got %o's%ious'ess. e %a't

%ommu'i%ate -ell, e %a' o&e' #er eyes -#e' #er 'ame %alled, +ut #e +a%

aslee& agai'. /#ere is 'o #istory o$ trauma or seiures +e$ore a'd is 'ot

a%%om&a'ied +y %#est &ai'.oss o$ %o's%ious'ess a%%om&a'ied +y -ea'ess

/#e &atie't %om&lai'ed o$ -ea'ess si'%e 3 days ago. Wea'ess

%o'ti'uously so t#at t#e &atie't %a' 'ot +e a%tiity a'd ee& -#e' sta'di'g.

Wea'ess does't im&roe -it# $eedi'g a'd dri'i'g. Wea'ess is 'ot

a%%om&a'ied +y omiti'g, 'o a%%om&a'ied -it# +la%is# s&ots a&&ear o' t#e

si' a'd is 'ot a%%om&a'ied +y liuid de$e%atio'. !e$e%atio' o'%e a day, t#ere is

'o +lood. 5ri'ate is redu%ed 263 times a day 12 glasses. &reiously &atie'ts

sto& i'je%ti'g i'suli' +e%ause it $eels t#e &ai'


4/16

Past History Disease2

Time Place of admission History of Therapy ortreatment

2012 RSDM DM tipe 2Use insulin rapid 101010

Family History Disease3!ia+etes mellitus : de'ied

y&erte'sio' : de'ied


5/16

Physical Examination4

A&atis , 84 4 M

General Appearance:

Vital Sin:

/ : 12070 mmg

N : 10;


6/16

Physical Examination4edem eyelid 666

(ale %o'ju'%tia >66?

*lera iteri 66

(a&il lida# atro$i >6?

J( RB2 %m, e'largeme't

lym&o'odi >6?

A'terior "#est:

). "#est eBB?, R@E>66?

edem su&erior 66

edem i'$erior 66

"or:

). )" 'ot see'

(. )" 'ot &al&a+le

(. "ardia% +order 'ot -ide'ed

A. 1st a'd 2'd #eart sou'd

i'%rease, regular,

murmur >6?

A+dome'

) : !( !!, e'etasi >6? A :(eristalti >B? N

( :tym&a'i, area trou+e tym&a'i

(. su&el, #e&arlie' 'ot &al&a+le


7/16

Date 2172014 satua' Nilai rujua'

Hemoglobin 1,1 gdl 13, 6 17,

Eritrosit 4, 106/ul 4,50 -

5,90

Hematokrit 41 F 33 6 4

Lekosit =,1 103/ul 4,5 -11

Trombosit 271 103/ul 150 -450

5reum 9 Mg/dl 10 -50

"reati'i' 0,= Mg/dl 0,6 -1,1

*D/ 13 u/l 0-35

*D(/ 2 u/l 0-45

Natrium 133 Mmol 136 -145

Ealium 4,0 Mmol 3,3 - 5,1

"lorida 100 Mmol 98-106

+sAg 'o'reati

D!* 42; Mgd

5 !a"oratory Examination


8/16

5 !a"oratory Examination

Asi#osis meta"olic partialcompansate#


9/16


10/16


11/16

6 DIAGN$SIS1. !M ti&e 2 'o' o+ese -it# Eetoasidosis !ia+eti%um

2. Mild #i&o'atremia


12/16


13/16

7 Plannin Dianose#

1. (ro$il li&id, $u'dus%o&y,mo'o$ilame'

2. D!(, D!2((, +A1" i$ %li'i%ally release


14/16

7

Plannin Monitorin

1. D"*, ital sig', +lood glu%ose #our

2. $luid +ala'%e4 #our

3. @DA = #our &ost %orre%tio'

4. Ealium

7

Plannin e#%cation1. Die e


15/16

jam GCS ital si!n G"S #ns$lin

01!00 84 4 M 110"#0$ %4&$ 24&$ '($4 ) ''4 SP ( iu"*r

02!00 84 4 M 110"#0$ %%&$ 24&$ '($4 ) 404 SP ( iu"*r0'!00 84 4 M 110"#0$ %4&$ 20&$ '($4 ) '+( SP ( iu"*r

04!00 84 4 M 110"#0$ %0&$ 20&$ '($4 ) '1+ SP ( iu"*r

0+!00 84 4 M 110"#0$ %4&$ 20&$ '($( ) 24% SP ( iu"*r

0(!00 84 4 M 110"#0$ %4&$ 20&$ '($# ) 1%% SP ( iu"*r

jam $rin

0(!00 1+00 ,,


16/16

TERIM- .-SI/

cc dr.ty kad

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