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MORNING REPORTIGD, Januari 25 th 2015
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Patient’s Identity
• Name Tn! "usu#
• $%e &0 y!'
• Re(i%i'n M'es(im• )'r* Mer+hant
• Date 25 January 2015
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$namnesis
• Chief complaint: Pain Foot Dextra
• Present illnes: Patient came to theemergency department with
complaints of
Nyeri kaki kanan post kll, px berhenti danparkir dipinggir jalan
naik sepeda motorditabrak dari belakang terkena keki sebelahkanan
dan langsung mengeluhkan nyeri
hebat pada kaki kanan bawah.• Vomiting (!, nausea ("!, headache
(!,
pingsan ("! , pta ("!,
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#namnesis
• $istory or past illness %" $istory of same illness denial"
$& 'enial" ' 'enial
" Pulmo disease 'enial" )ardio disease 'enial" $erbal medicine
consumption for many
years(!, coffe(!, *top smoking since +
year ago• $istory of family %
)irrosis $epatis("!
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Physi+ Eaminati'ns
• G-. &5/
• ita( .i%n
P 1340 mm6%Pu(se 2 4 minutes
RR 2& 4 minutes
Tem# /, 7-
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Physi+ Eaminati'ns
• 6ead and ne+* $nemi+84 i+teri+94+yan'sis94 dys#neu9
• Th'ra simetri+ :i(atera((y, retra+ti'n ;949
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-(ue and -ue
• ale + y.o
• $aematemesis
• Nausea
• #nemis
• -lack stool defecation
• 'yspneu since +
mounth ago
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Problem ist
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$ssessment
• 6aematemesis
• Me(ena e!+ sus# Gastritis Er'siC
• $nemia
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P(annin%
• P(annin% D
• )omplate blood
)ount
• */0&
• */P&
• 1aal ginjal
• -lood smear • *tool examination
• $bs#g
• P(annin% T
ID aserin% ('adn%1000++ (anFut
1500++42&h'urs InF! Pant'#ra'(e 21
am# i!=
PO! @(saCat +th2 -'nsu(t Internist
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MONITORING
Genera( -'nditi'n
-'m#(aint
ita( .i%n
Ha:'rat'ry
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Ha:'rat'ry indin%s• DiA +'unt 04043&41&42
• 6emat'+rit 13,1
• 6aem'%(':in /,0m%4dH
• Heu*'+yte 10!&00
• HED 04113
• Tr'm:'+yte 20!000
• 6s9$% Ne%atiC
• i((iru:in Dire+t 0,13
• i((iru:in T'ta( 0,&1
• .GOT
• .GPT 13• $(:umin ,1
• @rea /
• -reatinin 1,2
• GD$ 115
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• Du:ia ad'nam
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• Ta*e a #(anty 'C rest
• E#(ain t' the Cami(y a:'ut the +'nditi'n 'C this#atient
n'>, its disease, a:'ut its eaminati'ns,thera#hy and
inter=enti'n >i(( :e d'ne, and a(s'
a:'ut +'m#(i+ati'n and #r'%n'sis!
Education
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