MORNING REPORT

Tuesday Night, October 22th 2019

• New Inpatient (ER) : 3 Physicians In Charge :

• Io : dr. Magdalena
• Consultation (ER) : 2
• IA : dr. Ramadhan
• Consultation (ward) : 0 • IB : dr. Haris
• Death Case: 0 • II : dr. Adit
• III : dr. Iin Noor Chozin, Sp.P(K)
Referral Letter
IDx:
• Post gtk seizure dt hypoxic ischemic
encephalopathy dd susp meta brain
• Susp Tumor Mediastinum
• Susp HF

Dr. Ria, SpS

History Taking
Patient ID : Mrs. Mudrikah /48 yo/ER/BPJS
Chief complaint :
- She has been suffering from seizure since yesterday, 3x, ±3 minute, trauma (-), headache (-), fever (-)
- She has been suffering from shortness of breath since 1 year ago. It has been getting worse since 3 days ago. SOB
relates to activities. She usually sleeps on 1 pillow. DOE (+) History of leg edema (+), Paroxismal nocturnal
dyspneu (-), Limitation of activity (-), Night time awakening (-), but last night she felt chest thightness.
- She hasn’t been suffering from chest pain.
- She has been suffering from intermitten cough since 1 month ago. It has been getting worse since 3 days ago. It
has been accompanied with whitish sputum. History of bloody cough (-)
- She hasn’t been suffering from fever. Night sweating (-)
- Decreased of body weight (-). Decreased of appetite (-)
- Nausea and vomit (-)
- Urination and bowel habits are normal.
• History of previous disease : HT (+) uncontrolled, DM (-), TB (-), OAT (-), Asthma (-), Heart disease (-),
renal disease (-)

• History of family’s disease: HT (-), DM (-), TB (-), OAT (-), Asthma (-), Heart disease (-), renal disease (-)

• History of contact with TB patient: denied

• History of smoking : Patient denied that he was an active smoker nor passive smoker.

• Risk factor of HIV : Tattoo (-), multipartner sex (-), blood transfusion (-) IVDU (-) Alkohol (-)

• Occupation : house wife

• History of diagnosis and treatment :

• Patient was hospitalized in Mitra Delima Hospital because of seizure attack

• Patient has never been hospitalized before

Physical Examinations
• General appearance : looks moderate ill
• Level of consciousness : GCS E4V5M6 
• Vital sign
BP : 130/80 mmHg BW : 65 kg BMI Norm

HR : 88 bpm BH : 155 cm L 17-23

RR : 22 x/min BMI : kg/m2 P 18-25

Temp : 36 oC

• Head : Conjungtiva anemic -/- ; sclera icteric -/- ; oral thrush (-)
• Neck : JVP R+0 cm H20 at 30o, enlargement of lymphnodes region (-) , neck swelling (-)
• Thorax : Cor
‐ Insp : ictus invisible
‐ Palp : ictus palpable at ICS V MCL S
‐ Perc : RHM at parasternal line D ; LHM ~ ictus
‐ Ausc : S1 S2 normal, murmur (-), gallop (+)
Thorax
Insp : - Static D=S Scoliosis Ausc : - Breath sound Ant Post
(-) (ant / post)
- Dynamic D=S V V V V

Palp : SF Ant Post V V V V

N N N N V V V V
N N N N - Rh Ant Post
N N N N - - - -
- - - -
Perc : Ant Post - - - -
S S S S - Wh Ant Post
S S S S - - - -
S S S S - - - -
- - - -
Emphysema subcutis (-)
Abdomen : rounded, soefl, BS (+) normal, H/L unpalpable, no tenderness in palpation
Extremity : warm, edema
- -
- -
 Laboratory Finding
October 21th 2019 Laboratory Finding
Mitra Delima
October 22th 2019 Normal Value
RSSA
Hospital

WBC 16,300 12,170 /µL 4.700 – 11,300

Hb 15.3 13.4 g/dL 11,4 – 15,1

Hematocrite 46.1 43.6 % 38 – 42

PLT 242,000 186,000 /µL 142.000 – 424.000
ESR - - mm/jam <20
MCV - 104.3 fL 80 – 93
MCH - 32.10 Pg 27 – 31
MCHC - 30.70 g% 32 – 36
Eosinophil - 0 % 0–4
Basophil - 0.2 % 0–1
Neutrophil 89 82 % 51 – 67
Lymphocyte 9 9.8 % 25 – 33
Monocyte 2 8 % 2–5
Lymphocyte count
1,467 1,192 >1200
 Laboratory Finding Laboratory Finding
October 21th 2019 October 22th 2019 Normal Value (RSSA)
Mitra Delima Hospital RSSA

RBS 208 88 mg/dL < 200

Ureum 42 40.9 mg/dL 16,6-48,5
Creatinine 0.8 1.05 mg/dL < 1,2
SGOT 14 15 U/L 0 – 40
SGPT 19 14 U/L 0 – 41
Albumin - 3.84 g/dL 3,5 – 5,5
Bil Total - - mg/dL <1
Bil Direct - - mg/dL < 0,25
Bil Indirect - - mg/dL < 0,75
Sodium 145 - mmol/L 136 – 145
Potassium 4.7 - mmol/L 3,5 – 5,0
Chloride 104 - mmol/L 98 – 106
Procalcitonin - - mmol/L Darah vena : 0.5 – 2.2

Lactic Acid Darah vena : 0.5 – 2.2

- 1.5 mmol/L
Darah arteri : 0.5 – 1.6
 Laboratory Finding
Value
October 22th 2019 RSSA

PPT

Patient Secon
11.10 9.4 – 11.3
d
Control Secon
11.0
d
INR
1.07 < 1.5

APTT

Patient Secon
26.60 24.6-30.6
d
Control
25.5 Second
ECG (October 22th 2019) in RSSA
• Sinus Rhytm : HR 86 bpm Conclusion: rhytm 86 bpm
• Frontal Axis : normal
• Horizontal Axis : normal
CXR (October 22th 2019) in RSSA
Position: AP, symmetric
Soft tissue: normal
Bones: Costae D: flattening S: flattening
ICS D: normal S: normal
Trachea: pushed to the right
Hillus : D: thick
S: dte
Cor : Site: dte, covered by radiopaque homogen
Size: dte, covered by radiopaque homogen
Shape: dte, covered by radiopaque
homogen
Hemidiaphragm:
- D:decreased of level, flattening
- S: dte, covered by homogenous radioopaque
Costophrenicus angle:
- D: sharp
- S : sharp
Pulmo :
Conclusion :
D: radiopaque homogen appearance in middle area,
Tumor Mediastinum infiltrate forming air bronchogram
Pneumonia S : dte, covered by homogenous radioopaque
CXR (October 22th 2019) in RSSA
Position: Lateral
Pulmo :
radiopaque homogen appearance in middle area

Conclusion :
Susp Tumor Mediastinum
 BGA (October 22th 2019) in RSSA
BGA with NRBM 10 lpm
pH 7,19 7.35-7.45 Fi02 0,9
pCO2 75,9 mmHg 35-45 ((760-47)*0,9)-(75,9/0,8)
pO2 65,3 mmHg 80-100 546,825
Original PO2
HCO3 29,3 mmol/L 21-28 A-a DO2 (546,825-65,3)
BE 0,9 15,2366667 mmol/L -3 - +3 481,525
Severe
Sat O2 86,6 % > 95 FiO2 needed (481,525+150)/760
Hypoxemia
83,09539474

Before oksigen After oksigen therapy : Fi02 Needed : 83.09

therapy : O2 needed 8-9 lpm NRBM
• hypoxemia
Severe hypoxemia
• hypercarbia
Pneumonia Severity Index (PSI) / PORT SCORE

48

Total PORT score : 98 RC III

SOFA SCORE 4
 Initial Diagnose
1. Post gtk seizure dt hypoxic ischemic encephalopathy dd susp meta brain
2. Pneumonia CAP
3. Susp Tumor Mediastinum dt tymoma dd Limfoma dd Lung Tumor S T3NxMx st III ks 70-80
4. HF st C fc III dt suggestif VHD
5. Susp Pericardial Effusion
 Planning Diagnosis and Therapy
• Sputum gram culture DST
• BGA
• CT Scan Thorax contrast
• FOB
• Check lab LDH, AFP, β HCG in ward

17
 Planning Diagnosis and Therapy

• O2 6-8 lpm on NRBM

• IVFD NaCl 0.9% 1000cc/24 hours
• Inf. Levofloxacin 1x750mg IV
• PO Paracetamol 3x500mg
• PO Codein 3x10mg
• Others ~ Ts Neuro

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THANK YOU