dr.

Tama

MORNING REPORT
Monday, 14 Desember 2020

PHYSICIAN IN CHARGE :
IA : dr. Rama, dr. Ika, dr. Ros
II HCU : dr. Mazen
II Consultant : dr. Tama
II InCovit : dr. Husni
II UGD : dr. Yosi, dr. Fiqih
II UGD InCovit : dr. Duma
Chief : dr. Arde
Consultant : dr. A. Rifai, SpPD
 MEDICAL CONSULTATION
from Aesthetic and Reconstruction
surgery Department

Patient with
Closed Fracture os Zigomaticus Sinistra Pro Reconstruction
Hyperglycemia state

The aim of consultation

Management Diabetes perioperative
 Summary of Database
Mr. M/ 64 yo/ ward 19
Autoanamnesa
Chief Complaint:
Pain at left cheek
Present Illness:
- Patient complained of pain in the left cheek. the cheek looks bruised, the
patient falls off the motorcycle without wearing a helmet. The patient will
undergo cheekbone reconstruction by aesthetic and reconstruction
surgery.
- the patient said that the patient had previously had diabetes since 1 year
ago but did not routinely take medication
 Summary of Database
Past Medical History:
-

Family History:
His Father has History of Diabetes mellitus. He lives with her daughter.

Social History:
He is moslem, lived with her daughter and wife

Review of System:
Urination and defecation with normal limit.
 Physical Examination
General appearance looked moderately ill Sat 97% RA
GCS 456 BMI : 28,2 kg/m2 (Over weight) BW: 74 kgs
BP 125/70 mmHg PR 82 bpm regular strong RR 18 tpm Tax 36 oC
Head Conjuctiva Anemic (-), Sclera Icteric (-) hematome et region zigomaticus S crepitation(+)
Neck JVP R+ 2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -|- -|-

Sonor | Sonor Vesicular | Vesicular -|- - |-

Cardio Ictus invisible, palpable at MCL (S) ICS V
S1 S2 single, regular,
murmur (-), gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Warm acral
 Laboratory Findings (12/12/2020)
LAB VALUE NORMAL LAB VALUE NORMAL

Ureum 26,7 20-40 mg/dL

Leucocyte 9.540 4.700 – 11.300 /µL

Creatinine 0,54 <1,2 mg/dL

Hemoglobine 13,8 11,4 - 15,1 g/dl

PCV 38% 38 - 42% Natrium 132 135-145 mmol/L

Thrombocyte 377000 142.000 – 424.000 /µL Potassium 3,58 3,5-5,0 mmol/L

Eo/Bas/Neu/ 8,3/ 0,3/ 68/ 0-4/0-1/51-67/

Chlorida 109 98-106 mmol/L
Limf/Mon 23,0/ 3,9 25-33/2-5

RBS 310 <200

Total Antibody SARSCoV2 Non Reactive

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. M/ 64 yo/ ward 19 1. Closed Orthopaedy Department Pmo:

Fracture os - Bed Rest Subjective,
Subjective Zigomaticus - Diet 1800 kcal/day VS,
Diagnosed Closed Fracture os Sinistra - IV Metamizol 3x1 gr
Zigomaticus Sinistra pro - Pro reconstruction Pedu:
reconstruction zigomatikus Planning
Objective Teraphy
Hematom et Regio Sinistra
crepitation (+)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

2. Hyperglycemia 2.1 Stress - FBG/2hPPBG Non-Pharmacology: Pmo:

Mr. M/53 yo/ward 19 state Hyperglycemia - HbA1C - DM diet 1800 kcal day Subjective,
Subjective 2.2 DM type 2 (carbohydrate 810 kcal day, fat VS,
- Diagnosed Closed Fracture os
Zigomaticus Sinistra, controlled overweight 450 kcal day, protein 350 kcal
day) Pedu:
with insulin Patient
- T2DM history is denied
Pharmacology: compliance
- IVFD NaCl 0.9% 1500 cc/24 and lifestyle
Objective
BW: 74 kg, BMI: 28,5 kg/m2 hours modification
- OAD or Insulin waiting For
Fbg/bg2pp
Laboratory
RBS (17.00): 310 mg/dL - Target monitoring pre op, post
RBS (21.00): 161 mg/dL (Post op 140-180 mg/dL
Rehydration)
 TREATMENT GIVEN
BY AESTHETIC AND RECONSTRUCTION SURGERY DEPARTMENT

• IVFD NS 20 Tpm
• Inj. Metamizole 3x1 g
• Pro Os Zygomaticus Reconstruction
 We suggest this patient
PLANNING DIAGNOSE
- FBG/ 2H PPBG

PLANNING THERAPY
- Rehydration 500 cc  NS 1500 cc/day maintenance
- Diet 1800 kcal/ day (carbohydrate 55%, fat 20%, protein 25%)
- OAD or insulin waiting for FBG/ 2hppbg
- Monitoring glucose at 1 hour before induction, during operation, and the end
operation with target glucose 140-180 mg/dL

PLANNING MONITORING
- UOP, FBG, BG2pp/3 days, HbA1C

Patient will be collaborative cared with Endocrinology division

 Condition this Morning

• GCS : 456
• BP : 120/80 mmHg
• HR : 98 bpm
• RR : 19 tpm
• Tax : 36,6 oC