Download - Morning Report III
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21 November 2015
LAPORAN PAGI
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Name : Ny. NN Age : 49 TahunPekerjaan : PNSMRS : 01.12
Identitas
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Keluhan Utama : Mual terus-menerus post kemoterapi
RPSPasien datang ke RS diantar oleh keluarganya dengan keluhan mual terus-menerus. Diketahui bahwa pasien telah 4x melakukan kemoterapi oleh karena pasien menderita Karsinoma Mammae sejak setahun yang lalu. Pasien juga mengeluhkan nyeri pada luka yang terdapat pada payudara kanan pasien. Pasien juga mengeluh sulit menelan, selain itu keluhan demam (-), muntah (-).
Anamnesis
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Tekanan darah : 60/40 mmHgNadi : 130 kali/menitRR : 26 kali/menitSuhu : 37,90 C
Pemeriksaan Fisik
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Kepala & Leher
MataKonjungtiva : Anemis +/+Sklera : Ikterik-/-Pupil : Isokor 3mm/mm, reflex cahaya +/+
Hidung : Pernapasan cuping hidung (-)Leher : Massa (-),
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Inspeksi : Pergerakan dada simetris, reguler, abdominothoracal, tampak ulkus pada mammae dextra, perdarahan (+), pus (-), jaringan nekrosis (+)
Palpasi : vokal fremitus D = SAuskultasi : vesikular (+/+), ronkhi (-/-),
wheezing (-/-)
Thorax
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Inspeksi : distensi (-) Auskultasi : bising usus (+) Perkusi : bunyi timpani (+)Palpasi : defans muskular: (-)
Abdomen
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Looknormal
Feel normal
Move normal
Ekstremitas
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DL Hb : 11,7 g/dLLEritrosit : 4200000/uLLeukosit : 240/uL LTrombost : 16000/uLLUreum : 66.7 mg/dL HCreatinin : 1.31 mg/dL HNarium : 124 mmol/L LKalium : 3.0 mmol/L LKlorida : 89 mmol/L LGDS : 136 mg/dL
Pemeriksaan Penunjang
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Vomit Karsinoma Mammae on kemoterapi
Diagnosis
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IVFD D5 20 tetes/menitOmeprazole 1x40 mg(Vial)/IVKalnex 3x500 mg(amp)/IVOndasetron 3x4 mg(amp)/IVRawat luka
Rencana Terapi
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TERIMA KASIH