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    MR - 19-04-2018

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    dara agusti Maulidya
    The document summarizes a medical report for a 61-year-old female patient named Ny. Winarsih who presented with shortness of breath as her main complaint. She has a history of asthma and hyperthyroidism. On examination, she had wheezing in both lungs, low blood pressure, and abdominal tenderness. Tests showed elevated white blood cell count. Her problems were assessed as acute asthma exacerbation, hypotension, acute gastritis, and hyperthyroidism. She received treatments including oxygen, nebulizers, steroids, aminophylline drip, and medications to address her conditions.

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    MR - 19-04-2018

    Uploaded by

    dara agusti Maulidya
    3 views19 pages
    The document summarizes a medical report for a 61-year-old female patient named Ny. Winarsih who presented with shortness of breath as her main complaint. She has a history of asthma and hyperthyroidism. On examination, she had wheezing in both lungs, low blood pressure, and abdominal tenderness. Tests showed elevated white blood cell count. Her problems were assessed as acute asthma exacerbation, hypotension, acute gastritis, and hyperthyroidism. She received treatments including oxygen, nebulizers, steroids, aminophylline drip, and medications to address her conditions.

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    Morning Report Stase Paru

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    The document summarizes a medical report for a 61-year-old female patient named Ny. Winarsih who presented with shortness of breath as her main complaint. She has a history of asthma and hyperthyroidism. On examination, she had wheezing in both lungs, low blood pressure, and abdominal tenderness. Tests showed elevated white blood cell count. Her problems were assessed as acute asthma exacerbation, hypotension, acute gastritis, and hyperthyroidism. She received treatments including oxygen, nebulizers, steroids, aminophylline drip, and medications to address her conditions.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    3 views19 pages

    MR - 19-04-2018

    Uploaded by

    dara agusti Maulidya
    The document summarizes a medical report for a 61-year-old female patient named Ny. Winarsih who presented with shortness of breath as her main complaint. She has a history of asthma and hyperthyroidism. On examination, she had wheezing in both lungs, low blood pressure, and abdominal tenderness. Tests showed elevated white blood cell count. Her problems were assessed as acute asthma exacerbation, hypotension, acute gastritis, and hyperthyroidism. She received treatments including oxygen, nebulizers, steroids, aminophylline drip, and medications to address her conditions.

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    of 19

    Laporan Pagi

    19 / 04 / 2018
    IDENTITAS
    • Nama : Ny. Winarsih
    • Jenis Kelamin
    : Perempuan
    • Usia : 61 tahun
    • Alamat : Jalan Masuka Gang Aneka II,
    Kapuas Kanan Hilir, Sintang
    • Tanggal MRS : 18 April 2018 Pukul 23.45
    KELUHAN UTAMA
    • Sesak napas
    RIWAYAT PENYAKIT SEKARANG
    Pasien datang dengan keluhan sesak napas sejak 4 hari
    SMRS dan semakin memberat sejak 1 hari terakhir.
    Keluhan disertai batuk berdahak warna putih,
    memberat terutama di malam hari. Sesak dipicu oleh
    asap pembakaran sampah dan asap rokok. Pasien juga
    mengeluhkan badan lemah, nyeri kepala, mual dan ada
    muntah sebanyak 1 kali pagi hari tadi. Pasien sering
    berkeringat dan berdebar. Keluhan demam disangkal.
    Keluhan bengkak di kedua kaki disangkal.
    RIWAYAT PENYAKIT DAHULU
    • Riwayat asma (+)
    • Riwayat hipertiroid (+) dalam pengobatan
    • Riwayat tekanan darah tinggi (-)
    • Riwayat penyakit jantung (-)
    • Riwayat DM (-)
    • Riwayat merokok (-)
    RIWAYAT PENYAKIT KELUARGA
    • Tidak ada keluarga yang mengalami keluhan
    serupa
    Riwayat Pengobatan
    • Pasien sudah dibawa ke klinik 1 hari yang lalu
    dan mendapatkan nebulisasi.
    • Pengobatan dari poli paru:
    – Symbicort
    – Berotec jika sesak
    – Salbutamol
    – Teofilin
    • Pengobatan hipertiroid:
    – Thyrozol
    PEMERIKSAAN FISIK
    • Keadaan Umum : Tampak sakit sedang
    • Kesadaran : Compos mentis
    • Tanda Vital
    - Tekanan Darah : 95/80 mmHg
    - Frekuensi Nadi : 96 x/menit, reguler
    - Frekuensi Napas : 36 kali/menit
    - Suhu : 36,7 ᵒC, aksila
    - SpO2 : 92% , room air
    • Kepala : Normosefali
    • Mata : CA (-/-), SI (-/-)
    • Telinga : Sekret (-/-)
    • Hidung : Sekret (-/-)
    • Mulut : bibir sianosis (-), lidah kotor (-),
    Tonsil T1/T1
    • Leher : Pembesaran limfonodus (-)
    •Paru
    –Inspeksi : pergerakan simetris, barrel
    chest (-), sela iga tidak melebar
    –Palpasi : fremitus taktil sama bilateral
    –Perkusi : sonor di kedua lapang paru
    –Auskultasi : SND ves (+/+), rhonki (-/-),
    wheezing (+/+)
    • Jantung : BJ S1 S2, reguler, murmur (-), gallop
    (-)
    • Abdomen
    – Inspeksi : datar, distended (-), skar (-)
    – Auskultasi : bising usus (+)
    – Palpasi : nyeri tekan epigastrium (+), hepar tidak
    teraba, lien tidak teraba
    – Perkusi: timpani (+)
    • Ekstremitas :
    – Pitting Oedem - -
    - -

    – Akral hangat
    – Nadi teraba kuat
    PEMERIKSAAN PENUNJANG
    Laboratorium Darah Rutin
    • WBC : 9.440 /uL
    • PLT : 250.000 /uL
    • HGB : 12,0 g/dL
    • HT : 35,1%
    • MCV : 79,8 fl
    • MCH : 27,3 pg
    • MCHC : 34,2 g/dL
    Pemeriksaan Penunjang
    • GDS : 104 mg/dl
    • Ureum : 32 mg/dl
    • Kreatinin : 0,9 mg/dl
    Daftar Masalah Sementara
    1. Sesak napas
    2. Batuk berdahak
    3. Wheezing pada seluruh lapang paru
    4. Riwayat asma
    5. Hipotensi
    6. Nyeri ulu hati
    7. Mual
    8. Muntah
    9. Nyeri kepala
    10.Riwayat hipertiroid
    Daftar Masalah Tetap
    Analisa P Dx P Tx P Mo
    Sesak napas O2, 3LPM via NK Klinis
    Saturasi oksigen
    Asma eksaserbasi Spirometri - Nebu combivent 3 x Klinis
    akut 1 resp dalam 1 jam, Saturasi oksigen
    lanjut 1 resp / 8 jam Arus puncak
    - Inj. MP 62,5 mg / 12 espirasi
    jam Efek samping obat
    - Drip aminofilin 240
    mg / 12 jam
    - PO N-Ace 3 x 200
    mg

    Hipotensi - Loading RL 500 cc, Klinis


    lanjut 15 tpm.
    Daftar Masalah Tetap
    Analisa P Dx P Tx P Mo
    Gastritis Akut Endoskopi Inj omeprazole 40 mg / Klinis
    24 jam
    Hipertiroid Pemeriksaan PO Thyrozol dilanjutkan Klinis
    TSH, T3 dan
    FT4
    - Asma eksaserbasi akut
    - Hipotensi
    - Gastritis akut
    - Hipertiroid
    TERIMA KASIH

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