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Morning Report Friday, July 8th 2011

IA : dr. Meci, dr. Rusyda, dr. Supono IB : dr. Vindrya, dr.Amel II : dr. Maya III: Dr.Sri Sunarti SpPD,

SUMMARY OF DATA BASE
Mrs. Uyu n / 28 yo/W 28 (Heteroanamnesis) Chief complaint : general weakness • She felt general weakness since 2 months ago, worsening since 1 week before admission • She had low of appetite since 2 months ago, because nausea but not vomiting, and sometime she felt epigastric pain She ate about 3-4 spoon /ate, •According to her husband , she had leg swelling intermittently since 1 month ago, •Since 2 week ago, she had complain her chest felt pain, but not shortness of breath. (???) •She had history of gastritis since 4 years ago, sometimes took promag,

Physical Examination
General appearance Blood Pressure Pulse Rate Respiration rate T ax Looked severely ill GCS : 456 90/60 mmHg 100 tpm 24 tpm, 35.60C

Head
Neck Chest  Heart

Anemic (+), Icteric (-)
JVP R + 5 cmH2O at 30 0 position Ictus visible, palpable at ICS VI cm MCL S RHM SL (D), LHM≈Ictus S1 S2 single , murmur (+) diastolic Symetric SF D=S , V V V V V V Rh - --Wh -- S/S - - S/S -- S/S

 Lung

Abdomen Extremities

Soefl , Liver span 10 cm, traube space dullness(splenomegali s2), epigastric pain + Edema - +/ - + (pitting oedema), pale

Laboratory finding
Leucocyte Hemoglobine MCV MCH PCV Trombocyte RBS Ureum Creatinine SGOT SGPT Na K Cl LDH 7.300 6.0 73 24.7 17.6 316.000 102 17.0 0.60 13 10 139 3.8 94 % /µL mg/dl mg/dL mg/dL U/L U/L Mmol / L Mmol / L Mmol / L Mmol/L /µl gr/dl

Value
N: 3.500 – 10.000 N: 11,0 – 16,5 N: 80 - 97 N: 26.5 – 33.5 35 - 50 150.000 – 390.000 < 200 10-50 0,7 – 1,5 11 – 41 10 – 41 136 – 145 3,5 – 5,0 98 – 106 210-425

Lab Urinalysis

Value

Lab Value Laboratory Finding continued... 10 x Epithel Silinder Hialine Granuler Leucocyte Erytrocyte 40 x Eritrosit

SG
PH

Leucocyte
Nitrite Protein Glucose Eritrocyte

Keton urine
Urobilinogen Bilirubin

Leucocyte
Crystal Bacteria

CHEST X RAY
CXR : AP position, asimetric, KV enough, less inspirasi, soft tissue and bone normal. Phrenico costalis angle on Right and Left sharp, Hemidiaphragm D&S dome shape, Increase of BV pattern on Lung D, Thickening of hilus Cor site N, CTR 60%, Conclusion : cardiomegaly,

l

PROBLE MLIST

INITIAL DIAGNOSE

PLANING DIAGNOSE

PLANING THERAPY

PLANING MONITORING

Female / 28 yo 1. Anemi 1.1. Anemia Shortness of a defisiensi Fe breath,general hipokro weakness, low m intake 2 mikrosi months ter PE= pale conjunctiva HB: 6.0 gr/dl

Retikulosit BMP Blood thin & thick smear , USG abdoment

O2 2-3 lpm CBC IVFD NS 0,9 LL Folic acid 1x3tb, B12 3x1 tab, PRC transfusion 1 pack/day till Hb> 10 gr/dl

CUE AND CLUE Female /28yo Change of mental emosional Mutism

PROBLE MLIST 2. Psikosa

INITIAL DIAGNOSE 2.1. Schizophrenia

PLANING DIAGNOSE

PLANING THERAPY Confirmed diagnosed

PLANING MONITORING

Consul Psikiatri

VS Complain

Female/28yo SOB ? PE: JVP R+6 cm H2O Ictus visible ICS VI

3. HF.St.C Fc III

3.1 RHD Sequele 3.2 Anemia Heart Disease

Ecxhocardi ography

Semifowler VS position Complain O2 3-4 L/ m via N.C Furosemide 400-0 mg i.v Captopril 3 x 6, 25 mg p.o