MORNING REPORT ipd 040914.ppt

8/20/2019 MORNING REPORT ipd 040914.ppt

1/22

MORNING REPORTdepartment of internal

medicine04-9-2014


2/22

IDENTITY

• Name : Ny. K

• Ae : !4 y.o

•

"e# : female• Adre$$ : %amonan

• &or' : (o)$e*ife

• Date : A))$t+ 0,t( 2014


3/22

ANANE"I"

• /IE %AINT: /eadac(e• 3E"ENT I%%NE"" /I"T3Y :

atient came to t(e emerency department *it(complaint$ of (eadac(e $ince t(i$ mornin 1 (o)r efore(o$pital admi$$ion. (eadac(e i$ felt *(en *a'in+(eadac(e felt t(e cro*n $ection+ (i$ pain and tinlincontin)o)$+ $e5ere (eadac(e increa$e$+ )t $pontaneo)$lyred)ced after a fe* (o)r$. atien al$o complained of$(ortne$$ of reat( $ince 1 *ee' ao+ $(ortne$$ ofpercei5ed contin)o)$ly+ *(en t(e patient felt $(ortne$$acti5ity and $li(tly red)ced at re$t )t $till feel t(e

ti(tne$$. *(en t(e patient$ al$o feel c(e$t ti(tne$$ (eat)t not pain. , day$ ao 4 # t(e patient i$ al$o 5omitinand 6lled *it( *ater and food t(at (a$ een eaten. patiental$o complained of *ea'ne$$ $ince 2 day$ and left leean to $*ell. co)( 7-8+ cold 7-8+ normal o*elmo5ement$+ )rination i$ normal.


4/22


5/22

=ITA% "I>N :

>": 4?

@ : 1!;11? mm/B%"E 3ATE : 114 # ; min)te$

TE : ,?+?o

33 : 2# ; min)te$"po2 : 9 *it(o)t 2 $)pport --C 99

/Y"IA% EAINATIN


6/22

• Head and Neck :

Anemic 7-;-8+ Icteric 7-;-8+ yano$i$ 7-;-8+ Dy$pne)7-8

)pil i$o'or , mm ; , mm+• Pulmo:

In$pection :

- mo5ement of t(e c(e$t *all : $ymmetrical

- t(e $(ape of t(e c(e$t *all : normal+

- retraction 7 - 8 + protr)$ion 7 - 8 + reat(inpattern$ tac(ypne) .


7/22

- alpation : Tender 7 - 8 De5elopment of t(e c(e$t *all : normal Krepita$i 7 - 8

fremit)$ : normal %imit t(e l)n$ - li5er : I" ?

- erc)$$ion : re$onant- A)$c)ltation: %)n "o)nd$ : erip(eral

p)lmonary 5e$ic)lar 6eld Additional$o)nd : crac'le$ 7 - 8 *(eeFin 7 - 8


8/22

Cor

• In$pection : =oi$$)re cardiac 7 - 8 + epia$tricp)l$ation 7 - 8 +

alpation : ict)$ cordi$ i$ not $tron liftpalpation+ t(rill fremi$$ement 7 - 8

• erc)$$ion : %imit t(e (eart : t(e ri(t7 para$ternal line de#tra ic$ = 8 + left 7 %$ini$tra ic$ = 8 + *ai$t (eart 7 - 8 + t(e )pper

limit dn• A)$c)ltation : a (eart m)rm)r 7 - 8 +

pericardial friction r) 7 - 8 + eofoni 7 - 8


9/22


10/22

l)e and )e

• female+ !4 year$ old

• ep(alia

• Tac(ipne)

•

&ea'ne$$• oedem


11/22

A$$a$ment

• (epalia

• /yperten$i $tae 2

•

Dy$lipidemia


12/22

lannin Diano$e

• @

• /emo$tatic f)nction

• /epar f)ntion

• 3enal f)ntion

• >DA

•

E>• Electrolite $er)m

• -3ay T(ora#


13/22

lannin T(erapy

• 2 10 lpm

• A$erin 00 ;24 Gam

•

InG etamiFon 2 # 00 m• InG 3antin 2 # 0 m


14/22

onitorin

• =ital $in$

• omplaint


15/22

rono$i$

• D)ia ad onam


16/22

Ed)cation

• E#plaine to t(e family ao)t t(edi$ea$e of t(e family+ ao)t it$t(erap(y and inter5ention *ill e

done+ and al$o ao)t complicationand prono$i$.


17/22

%aoratori)m• DiHco)nt ,;2;?,;2!;• /emato'rit ,?+!• /emoloin 12+4• %ED 10;20• %e)'o$it .200• Tromo$it 2,0.000• ">T 1• ">T 1

• Kali)m $er)m 4+• Brea 94• "er)m creatinin 0+!• (ole$terol ,1• %D% '(ole$terol 1!+9• Trili$erida 201• >DA 12!


18/22


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MORNING REPORT ipd 040914.ppt