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  • Morning Report - Kelompok 4

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    Novina Firlia
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    This patient was admitted to the hospital on January 19th 2015 with shortness of breath, cough, night sweating, and weight loss. They were assessed as having relapsed lung tuberculosis based on clinical findings and test results. Initial therapy included oxygen via nasal cannula, intravenous antibiotics and medications, high calorie and protein diet, and further examinations and testing. The patient was hospitalized for treatment and monitoring of their condition.

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    This patient was admitted to the hospital on January 19th 2015 with shortness of breath, cough, night sweating, and weight loss. They were assessed as having relapsed lung tuberculosis based on clinical findings and test results. Initial therapy included oxygen via nasal cannula, intravenous antibiotics and medications, high calorie and protein diet, and further examinations and testing. The patient was hospitalized for treatment and monitoring of their condition.

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    11 visualizzazioni2 pagine

    Morning Report - Kelompok 4

    Caricato da

    Novina Firlia
    This patient was admitted to the hospital on January 19th 2015 with shortness of breath, cough, night sweating, and weight loss. They were assessed as having relapsed lung tuberculosis based on clinical findings and test results. Initial therapy included oxygen via nasal cannula, intravenous antibiotics and medications, high calorie and protein diet, and further examinations and testing. The patient was hospitalized for treatment and monitoring of their condition.

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    Morning Report

    January 19th 2015

    Ny. S Date of admission: January 19th 2015


    Cc: Breathless since 1 days before admission MR: 94 – 28 – 06 – 00

    Findings Assessment Therapy Planning


    Shortness of breath, cough , night sweating,
    1. relaps Lung TB Initial Therapy: Pro Hospitalized
    decreasing body weight
    O2 Nasal canule 3lpm Diet: high kkal high protein
    Pharmacotherapy:
    BP: 150/100 mmHg 1. Ceftriaxone 1 x 2 gr
    PR: 88x/min 2. Ranitidine amp 2 x 1
    IVFD: II RL / 24 hours
    RR: 26x/min amp
    Temp: 36,70 c 3. Ambroxol hcl 3 x 1
    tab
    Eye: Icteric Sclera -/- ; Anemic Conjunctiva -/- Pharmacotherapy:
    Thorax Ceftriaxone 1 x 2 gr
    Ins: Move symetrically, ictus cordis (-) Ranitidine amp 2 x 1 amp
    Pal: VF +/+, Ictus Cordis (-) Ambroxol hcl 3 x 1 tab
    Per: Sonor symetrically, Dull in heart
    Aus: Base Respiration Sound  bronkovesicular
    Examination :
    Ronchi +/+ ; Wheezing - / -, Heart sound I & II
    Sputum test
    normal, extra heart sound (-)
    Abdomen
    Ins: stout, distended (-)
    Aus: Bowel sound + 5x/mnt
    Pal: Tenderness (-)
    Per:tympanic
    Extremities
    Edema -/- ; CRT <2”; Warm
    Laboratory
    HB : 8,4 , L : 9,8 , HT : 23,9 , T : 245
    Blood Glucose: 175 mg/dl

    Ro thorax : infiltrate on both basal lung,


    calsification and fibrotic sign
    ECG: regular, sinus rythm

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