Morep Interna 2 Oktober 2015

8/18/2019 Morep Interna 2 Oktober 2015

1/18

EMERGENCY ROOM

MORNING REPORTINTERN MEDICINE DEPARTMENT


2/18

IDENTITY

• Name : Mr. N

• Age : 40 y.o

• Sex : Male

• Address : Bay!"ag# RT$ R% 4& Mayar&Gres#'

• Da(e o) exam#a(#o : O*(o+er $s(& ,0$-


3/18

ANAMNESIS

C#e) *om/la#(B!r#g sesa(#o # (e (roa(

Prese( Illess #s(ory

Pa(#e( *om/la#ed a +!r#g sesa(#o # #s (roa(

s#*e a "ee' ago. I( )el( l#'e (ere "as a /legm # (e(roa(. Co!g 123 s#*e a "ee' ago. e also *om/la#eda+dom#al d#s(es#o s#*e - mo(s ago. S#*eyes(erday oo& e )el( +loa(#g s(oma*& a!sea ad)eer. Tere "as o (re" !/ 153. Te )eer "as r#se ad

do". S#er 153. Pa# o #s s(oma* 153. De*reased #a//e(#(e 123. 6#m/ 123. e also ad m#*(#o o)(e(#mes.D#7*!l(y # de)e*a(#o. e ad s"ell#g o +o( o) #slegs s#*e a "ee' ago a)(er ge((#g #8e*(#o # os/#(al# Malag 1 Pa(#e( ad #s )am#les d#d9( a"are "a( (e

med#*a(#o "as 3.


4/18

• Pas( Illess #s(ory : e ad +ee (rea(ed # os/#(al+e*a!se o) a+dom#al d#s(eded # ,0$- ad "asd#agosed *ro#* e/a(#(#s B ad e/a(oma. D#a+e(esMell#(!s ad y/er(es#o "as de#ed. De/ressed Illess

123• am#ly Illess #s(ory : Tere "as o )am#ly "o ad (e

same *om/la#(

• So*#al Illess #s(ory : e ad o #s(ory o) *os!m#gal*ool ad (rad#(#oal med#*#e


5/18

PYSICA6 E;AMINATION

• Geeral s(a(!s : loo's !"ell& *om/osme(#s

• GCS :4-<

• =#(al S#g

5 BP : $$>?0 x?m#!(es& (ora*oa+dom#al (y/e

5 T : >@., C


6/18

Head/neck • ead : Normo*e/al• eyes : *o8!g(#a aem#s5?5& s'lera #*(er!s 2?2& ro!d /!/#l

#so'or > mm?>mm& l#g( reex 2?2•

ose : se/(!m de#a(#o 5& se*re( 5• mo!( : *yaos#s 5& "e( m!*osa 2& "#(e s/o( # oral *a!m

153& s(oma(#(#s 153• e*' : elargme( o) (yro#d glad 153& I*reas#g o) =P 153

Chest : ormal& syme(r#& re(ra*(#o 5?5& s/#der e#5

6!g• I : normochest & re(ra*(#o 5?5• P: )rem#(!s (a*(#l em#(orax r#g(le)(• P: soor• A : es#*!lar?es#*!lar& ro*# 5?5& "ee#g 5?5

ear( :• I: #*(!s *ord#s o( #s#+le• P: I*(!s *ord#s !/al/a+le& thrill/fremissment 153• P: ear( "a#s( # ICS III 6PSS& (e le)( s#de # ICS = 6MCS& (e

r#g( s#de # ICS I= l#ea s(eral#s dex(ra• A: S$ S, & reg!lar& gallo/ 153& m!rm!r 153


7/18

Stomach :

• I : d#s(eded& s*ar5& darm contour F& darm s(e#)!g 5&*alla(eral e#s 5& *a/!( med!sae 5

• A : Bo"el so!d 123 ormal• P : defans muscular 2& (ederess 5& l#er "as /al/a+le

@ *m +elo" ar*!s *os(ae "#( #rreg!lar )orm& +l!(edge& ad ard sol#d *o*#s(e*y. S/leomegaly 123

• P : y/er(#m/a#& me(eor#sm!s 2

Extremity :

a#e 2?2& /#((#g edema a( reg#o *r!rs# D5S& a*ral "armdry red 2?2& er#(ema /almar 5& CRT , se*ods


8/18

P6ANNING DIAGNOSIS

• CBC

• Ele*(roly(e Ser!m

•

6T• AP

• BGA

• Torax /o(o

• ECG

• SG A+dome


9/18

6ABORATORY INDING

• To(al /ro(e# : -.,• Al+!m# : >• Er#(ro*y(e : >.>,• ema(o*r#( : ,J.JK

• + : J.L mg?dl• 6#m/o*y(e: L• Baso/#l: 4.L• Eos#o/#l : ,• Moo*y(e : ,

• 6e!*o*y(e : $$000• Ne!(ro/yl: L>.,• Trom+o*y(e :

>J0000

• re!m : ,0• Crea(##: 0.-• Clor#de : @-• Na(r#!m : $$,• 'al#!m 4.0• SGOT : ,,-• SGPT : >0• MC=: J0.$• MC : ,J.-0• MCC : >,.L• RD%: $-• MP=: >• 6ED $ : $J• 6ED , : 4@

• Be : @-

• Bee*): 5>.$

• CO> : ,,.L

•

*( : >-• /CO, : ,L.,

• / : @.4@L

• /O,:


10/18

TORA; AP TIDR


11/18

ECG


12/18


13/18

C6E AND CE

Male& 40 y.o B!r#g sesa(#o # (e (roa( Co!g 123 s#*e a "ee' ago

A+dom#al d#s(es#o Bloa(#g s(oma* a!sea )eer edema o +o( legs I*(er#* Aem#a y/oal+!m#em#a


14/18

ASSESMENT

e/a(oma

As*#(es


15/18

P6ANNING TERAPY

• O, asal > l/m• I=D RA $000** ?,4 • I8. Ce)o(ax#me >x$ gr #

• I8. !rosem#de ,x ,0 mg• e/amax ,x$• PO !rosem#de $5050• PO S/#rola*(o ,x $00 mg

• e/amer sa*e( $x$• S#/roe/(ad# C6 0505$• am+roxol >x$ (a+• Cos!l(: I(er#s(


16/18

PROGNOSIS

• D!+#a ad malam


17/18

Pa(#e( *om/l#a*e

=#(al s#g

6T


18/18

Ex/la# (o (e /a(#e(9s )am#ly a+o!( (ed#agos#s& e(#ology& #(ere(#o o) (era/y ad#(s r#s'& *om/l#*a(#o& ad /rogos#s.

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Morep Interna 2 Oktober 2015

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