Morning Report

25 oktober 2018
anastesi
J30
 OB LIST (pro ICU)
1. Ny. Ngatmi'ah  Anemia, DM tipe 2, asidosis, HT, CKD
2. Ny. Kismiati  TB paru, asidosis, CHF
 Patient’s Identity

• Nama : Ny. Ngatmi'ah

• Umur : 70 th
• Tanggal masuk: 24 oktober 2018 jam 00.30
 Anamnesis
RPS

Keluhan utama Rujukan dari Pkm brondong dgn DM+ HT + IMA

Pasien datang dengan keluhan sesak sejak kemarin
malem tiba-tiba ketika mau tidur, sesak sebelumnya
Sesak disangkal, batuk pilek-, pasien sempat mengalami
penurunan kesadaran sejak 3 jam SMRS, namun
sekarang sudah tersadar. Mual muntah-, makan
minum dbn, BAB BAK dbn.
 Anamnesis
RPD
HT+, DM+ tidak terkontrol, Stroke 2011
opnam di RSML
RPK
Terdapat keluarga pasien ya venderita HT+,
dan DM+
RPSos

-
 Physical Exam
Primary survey
Vital Sign A : clear, gargling (-), snoring (-), speak fluently
• TD : 219/94mmHg (+), potensial obstruksi (-)
• Nadi: 106x/menit B : spontan, RR 32x/menit, ves/ves, Rh +/+,
• Temp : 36.7CC Wh -/-, SaO2 %82 tanpa O2 support
• RR : 32x/min C : Akral HKM, CRT < 2” N 106x/menit TD
219/94mmHg
D: GCS: 456, lateralisasi:-, PBI 3mm/3mm, RC
+/+
E : temp 36,7
 Physical Exam
General Status
• General condition : lemah
• Kesadaran : compos mentis
• GCS : 456
• H/N : a-/i-/c-/d+
 Physical Exam
• Secondary survey
• GCS 456
• K/L: a -/ I -/c -/d +
• Tho: sim, ret -/-,
• P: ves/ves; rh +/+, wh -/-,
• C: S1S2 tgl, murmur -, gallop -
• Abd: soepel, met -, BU + N, H/L ttb
• Ext: aie - , akral HKM
 Clue and Cue
•Perempuan, 70 tahun
•Sesak napas
•TD 219/94 mmHg
•Nadi 106 x/menit
• SaO2 82%
•Riwayat DM, HT
 Planning Diagnosis
•DL
•GDA
•BGA
•SE
•Thorax photo
 Assesment
•Type 2 Diabtes Mellitus
 Laboratory Findings
• HsThroponin I --> Hasil : 0.94 [ 0.00 - 0.1 ug/L ] • tHb --> Hasil : 8.8 [ ]
• Gula Darah Acak --> Hasil : 248 [ ] • • Neutropil --> Hasil : 88.0 [ 49.0 - 67.0 ]
Lekosit --> Hasil : 18.5 [ 4.0 - 11.0 ]
• Urea --> Hasil : 110 [ 15 - 43 ]
• Serum Creatinin --> Hasil : 3.2 [ P 0.7 - 1.2 • .Limposit --> Hasil : 2.7 [ 25.0 - 33.0 ]
• L. 0.8 - 1.5 ]
• SGOT --> Hasil : 60 [ 0 - 35 ]
• Monosit --> Hasil : 2.2 [ 3.0 - 7.0 ]
• SGPT --> Hasil : 60 [ 0 - 35 ]
• Eosinopil --> Hasil : 6.3 [ 1.0 - 2.0 ]
• .Kalium --> Hasil : 5.14 [ 3,50 - 4,50 ]
• .Natrium --> Hasil : 141.4 [ 135,0 - 148,0 ] • Basofil --> Hasil : 0.8 [ 0.0 - 1.0 ]
• Be --> Hasil : -6.6 [ ]
• Beecf --> Hasil : -6.9 [ ] • .Eritrosit --> Hasil : 3.01 [ 3.80 - 5.30 ]
•
•
cHCO3 --> Hasil : 20.6 [ ]
Clorida --> Hasil : 108.5 [ 98,0 - 107,0 ]
• .Hemoglobin --> Hasil : 8.9 [ P13,0 - 18,0
• Hct --> Hasil : 27.3 [ 51,0 - 61,0 % ] • L14,0 -18,0 ]
• iCa --> Hasil : 1.123 [ 1,420 - 1,720 mmol/L ]
• PCO2 --> Hasil : 49.7 [ 35,0 - 45,0 ] • Hematokrit --> Hasil : 27.4 [ L 40 -54
• pH --> Hasil : 7.235 [ 7,350 - 7,450 ]
• PO2 --> Hasil : 174.3 [ 80,0 - 100,0 ]
• P 35 - 47 ]
• SO2 --> Hasil : 99.1 [ 75,0 - 99,0 ]
• MCV --> Hasil : 91.00 [ 87.00 - 100 ]
 Re-Assesment
•Anemia ( D.64 .9\- )
•DM Type II ( E.11.\-- )
•Acidosis ( E.87.2\- )
•Hypertensi Essensial ( I.10.\- )
•CKD / CRF ( N.18.\- )
 Planning Therapy
• O2 NRM 10 lpm --> SpO2 100%
• inf RL LL
• pasang DK --> residu 100cc
• pump NTG mulai 20mcg/menit
• inj. Furosemid 2 ampul bolus --> maintenance pump 5mg/ jam
• inj. Cebactam 2x1g iv
• inj. Panloc 1x40mg iv
PLANNING MONITORING
Planning Monitoring

•Vital Signs
•Patient’s complaint
•Adverse effect
 PLANNING EDUCATION
Planning Education

Explain to the patient and his family about the

disease, cause, complication, intervention of the
therapy and prognosis.
Terimakasih