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MORNING REPORT

PHYSICIAN IN CHARGE:
I A : dr. Nando , dr. Idham, dr. Vina
I B : dr. Etik dr. Lailatul, dr. Yasmitha
II : dr. Suyoso
III : dr. Rulli Rosandi, SpPD
MODERATOR : dr. BP Putra Suryana, SpPD-KR

Summary of Data Base
Darinah /70 y.o/w. 26
Chief

complain:

Decreased

of

consciousness

(Heteroanamnesis

her

daughter)
• Patient presented with decrease of conciousness 3 days before admission.
The decrease of consiousnees happened gradually. At first, patient fell in
the bath room when she was cleaning the bath room. After she fell down
she can still go to the her room, but after that she can not freely moved.
After 2 days at home, she began to loose her apptetite, the ate only 1-2
spoon/day.
• After 2 days, because the patient still feel weak (but she can still
communicated), she sent to hostpital.At the time the blood glucose is 580
mg/dl. Patient have history of diabetes melitius, uncontrolled. She

just

come to doctor if there she feel unwell. Before she feel unwell, the sons of
patient tell if there is no compllaint with her eat.

She was hospitalized in prasetya hospital for 10 days. After 3 days.Summary of Data Base Her weight body has been decreased since couple years ago. After that she was sent to hospital again and get catheter and the colour of urine is also yellow. the colour urine is turbid yellow. She reffered to RSSA History of family: unremarkable. a house wife. having 4 children. the patient feel can’t urinated. Social history: married. unroutinely controlled for diabetes . She sent to batu hospital for further examination and the conclusion is she get renal infection.

traube’s space thympany shifting dullness + Extremitiey Skin Edema Contractur + + + + Warm acral RF 1 1 Motoric 3 3 RP B/C/O/G/T : -/-/-/-/1 1 3 3 MS (-). Liver span 5 cm. 300 position Lnn.regular RR = 16 tpm Tax = 36. soefl.- + + + . Enlargement (-) Thorax Heart Ictus invisible & palpable at ICS V MCL S.5 0C Head Conjunctiva Anemic (-) Sclera Icteric (-) cyanosis (-) edema (-) Pupil isocor (+) 3/3 mm meningeal sign - Neck JVP R + 3 cm H20.- ++ + + . murmur (–) Lung Symetric Stem fremitus D=S Sonor + + Neck stiffness (-) Rh + + Wh . bowel Sound (+) N.- + Abdomen Flat . RHM ~PSL D. . LHM ~ ictus S1 S2 single regular.PHYSICAL EXAMINATION General appearance looked severely illness GCS 223 Looked underweight BP= 100/60 mmHg PR = 92 bpm.

29 16.90 (11.1-11.5/1.0 mmol/l 11-16.5/3.80 40-47 % Thrombocyte 401000 Value Na 0.30 (28.30 0.1/0.80 27-31pg Creatinin PCV 34.6-48.6) SGPT/ALT 8 11-41U/L APTT 30.5-5.9-30.2 mg/dL Inr 0.1/9 0-4/0-1/514.LABORATORY FINDINGS Lab Leucocyte Diff count Haemoglobin Value 23310 4000-11.6) Osmolarit as 273 .5 mg/dL < 1.70 80-93 fl Ureum MCH 27.99 3.5 g/dL Cl 91 98-106 mmol/l MCV 80.97 RBS 187 < 200 mg/dL SGOT/AST 17 11-41U/L PPT 10.0 Lab 150-450x103/µL 11. 67/25-33/2-5 % 5 12.000/µL 124 136-145mmol/l K 1.

8.5 .URINALISIS Lab Value Lab Value Cloudy claudy Clear 10 x Color yelow Yellow Epitel ≤ 1lpf 4.0 Cilinder Lpf 1.0 BJ 1.015 Glucose +1 Negative Granular Protein trace Negative 40 x Keton - Negative Erythrocyte Bilirubin - Negative Dysmorfic Hpf Urobilinogen - Negative Eumorfic Hpf Nitrit - Negative Leucocyte Leucocyte +2 Negative Cristal Blood +2 Negative Bacteria Others 6 205 ≤ 3 hpf ≤ 5 hpf hpf 1615 ≤ 23 x 103/mL .015 Hialin ≤2 Negative pH 7.010 – 1.

57 7.35-7.BLOOD GAS ANALYSIS (NRBM 10L/M) BGA Value Normal Value PH 7.45 PCO2 35.7 -3 until +3 mmol/L O2 saturation 98.5 > 95% Conclussion Metabolic alcalosis .7 80-100 mmHg HCO3 32.8 21-28 mmol/L Base Excess 10.2 35-45 mmHg PO2 True O2 : 146.

ECG .

32” Conclusion : sinus tachycardia with HR 100 bpm . Heart rate 100 bpm Frontal Axis : Normal Horizontal Axis : Normal PR interval : 0.12” QRS complex : 0.08” QT interval : 0.ECG       Sinus rhythm.

CXR .

KV enough. less inspiration  Soft tissue thin. asymmetrical.Chest X-Ray AP position. Bone normal  Trachea in the middle  Hemidiaphragm D /S is dome shape  Phrenico cotalis angle D/S is sharp  Pulmo D/S : fibroinfiltrat upper area lung D & S  Cor site N.pneumonia  . size : CTR 50 % Conclusion : lung TB.

1.2 diabetic foot . leucocyte looks so decrease. CVA Planning Teraphy Bed rest O2 8-10 lpm/mnt NC Insert NGT fluid diet 6 x 100cc Insert catheter urine Equal Fluid balance IVFD NaCl 0. DOC Initial Diagnosa Planning Diagnosa 1.1.sepsis 1. VS.9% 20 dpm Infus ciprofloxacin 2 x 400 mg IV Per NGT: Clindamycin 3 x 300 mg Planning Monitoring & Education S.POMR Cue and Clue Male/41yo/ w26 Ax: Decrease of conciousness Nausea and vomiting Wound in left foot PE: GCS 223 BP: 130/90 mmHG PR: 105 bpm RR 26 tpm Ronkhi + all over lung area Rash all over the body Lab: Leuko 150/uL Blood smear: normochrom normocytic.2 scabies? Blood culture and sensitivit y 1.1.1 skin infection 1. UOP .2. trombosit looks Problem List 1.

urine culture and sensitivit y test Gram scraping Planning Teraphy Bed rest O2 NRBM 10 L/m Equal fluid balance Inserted NGT and catether Liquid diet 6 x 100 cc IVFD NaCl 0.2 pneumoni a 2. sputum.20/13.5 HPF Bacteria: Problem List 2. VS.1 diabetic foot 2.2 scabies? 2. Sepsis Initial Diagnosa 2.POMR Cue and Clue Male/41yo/ w26 Ax: DOC Sufferd liver cirrhosis PE: GCS 224 Rhonki + all area of the lung Rash all over the body Wound at left foot Lab: Leuko 25740 Bil T/D/I: 45.1.84/32.3 UTI Planning Diagnosa Blood.9% 20 dpm Infus ciprofloxacin 2 x 400 mg IV Per NGT: Clindamycin 3 x 300 mg Wound toilet and debridemant Planning Monitoring & Education S.1 skin infection 2. 64 Albumin 3. UOP .1.03 g/dL UL: Leukocyte: 8.

0 Lab: Leuko 150 3. VS.Male/41yo/ w26 Ax: Newly diagnosed DM Wound at left foot since a month ago PE: Pulsation: strong arteri dorsalis pedis Extent: 5-8 cm Depth: dermis Infection: pus. UOP Left pedis Xray . Diabetic foot wagner II POMR Mechanical and educational control: Use thick and soft soles sandals and shoes Microbiological: perNGT: clindamycin 3x300 mg Metabolic control: Plan for insulin Vascular control: Plan for arteriography and USG Doppler Wound control: debridement and wound dressing Education S. blood Sensoris: normal ABI score: 1.

770 cc in 1-2 hours and continued with 770 cc in 3 hours and than maintenance 20 dpm Planning Monitoring & Education S. UOP . VS.POMR Cue and Clue Male/41yo/ w26 Lab: Na 125 mmol/L K 3.14 mmol/L Osmolaritas 273 mmol/L Problem List Initial Diagnosa 4.Hponatr emia hypoosm olar hypovole mia 3.1 dehydratio n 3.2 poorly intake Planning Diagnosa Plasma spesific gravity Planning Teraphy Rehydration 1470 cc.

1dt septic 5.Lung infection 6.1 pneumoni a 1.2 tb with secunder infection Fast acid As above Subjective VS Rhonki all area of the lung Lab: CXR: fibroinfiltrat .POMR Cue and Clue Problem List Initial Diagnosa Planning Diagnosa Planning Teraphy Planning Monitoring & Education Male/41yo/ w26 Lab: Leuko 150 RBC 3 x 106 5.2 MDS 5. Bisitopeni a 4.2. VS. anemia aplastic Blood smear BMP Confirm diagnosed S. UOP Male/41yo/ w26 6.

Skin rash 9.canalliculi 9. painless. crustae.1 Scabies 9. ichy. DM type 2 newly diagnose d Planning Teraphy Planning Monitorin g& Educatio n Plan for insulin therapy S VS FBG PP2HBG HbA1c Confirm diagnose Subjective VS LF: RBS: 137mg/dL Male/41yo/ w26 Ax: Ichy all over the body PE: rash all over the body.POMR Cue and Clue Male/41yo/ w26 Ax: Suffered from diabetes Decrease of body weight Polyuri Polydipsi PE: Mucle atrophy Dry skin Problem List Initial Diagnosa Plannin g Diagnos a 8.2 Streptoc occal infection Gram scrappin g .

UTI Pneumonia Sepsis DOC DM type 2 Skin infection Bicitopeni .

AIDS. SBP cellulitis.Risk Factor of Sepsis  Very young people and elderly people  Anyone who is taking immunosuppressive medications (such as transplant recipients)  People who are being treated with chemotherapy drugs or radiation  People who have had their spleen surgically removed (the spleen helps fight certain infections)  People taking steroids (especially over the long term)  People with longstanding diabetes. meningitis. urinary tract infection . or cirrhosis  Someone who has very large burns or severe injuries  People with infections such as • • • • • pneumonia.

Management Analysis Bed rest O2 8-10 lpm/mnt NC Insert NGT fluid diet 6 x 100cc Insert catheter urine Rehydration 1470 cc. 770 cc in 1-2 hours and continued with 770 cc in 3 hours and than maintenance 20 dpm Equal Fluid balance IVFD NaCl 0.9% 20 dpm Infus levofloxacin 1 x 400 mg IV Inj gentamycin 2 x 40 mg iv Per NGT: Clindamycin 3 x 300 mg .

Mechanical and educational control: Use thick and soft soles sandals and shoes Microbiological: perNGT: clindamycin 3x300 mg Metabolic control: Plan for insulin Vascular control: Plan for arteriography and USG Doppler Wound control: debridement and wound dressing .

Condition Patient This Morning • • • • • • GCS BP PR RR Tax : 223 : 130/80mmHg : 88 bpm : 22 tpm : 36 0C .

THANK YOU .