MORNING REPORT

ICU ward
December, 07th 2021
 Patient Identity
• Name : Mr. SBA
• Age : 55 years old
• Sex : Male
• Occupation : Employee
• Education : Senior High School
A 55 year-old Man was admitted to R.D. Kandou
Hospital at A ward then moved to ICU

December, 07th 2021

Chief complaint: Abdominal Paint

 Present Medical History
• The patient came in with complaints of Abdominal pain since the last 1 month
but felt it was getting worse in the last a week. The stomach feels tense and the
patient feels cramped sometimes.
• In the last 1 week , the patient began to feel weak and lost his appetite. The
patient's wife also said that his stomach had enlarged in the last 3 months,
accompanied by nausea but no vomiting.
• The patient also complaints of yellow body, experienced in the last 1 month,
initially only the face, and eventually the body. A day before admitting the
patient fell while trying to go to the bathroom because he was weak.
• Denied fever, denied chest pain. The stomach feels full . No complaints of
defecation and urination no complaints.
• Then the patient was treated in the surgical treatment room and undergo a
cholecystostomy operation
 Past Medical History
• In the last 1 month, routine control at the digestive surgery
division because there is a problem with bile duct.
• No History of Hypertension, Diabetes, Dislipidemia, Kidney
disease, Heart disease.
 Family History
• None experienced the same illness
 Physical Examination
• GC: Severely ill . Sens : Apathy
• Vital sign : BP: 106/82mmHg, PR 101x/m, RR 20x/m, T
36.6oC, SpO2 99% via NC 3lpm
BW : 65 kg H: 170 BMI : 22.43
• Head : conj. anemic (+), scl. icteric(+)
• Neck : JVP 5+2m H2O, lymph nodes enlargement (-),
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC palpable
– Perc : left border: ICS V left midclavicular line
right border: ICS IV right parasternalis line
– Ausc : SI-II regular, murmur (-), gallop (-)
 Physical Examination
• Lung :
Insp : Symmetric R = L
Palp : Stem fremitus R = L
Perc : Sonor at both lung fields
Ausc : Vesicular, rhonci -/- wheezing -/-
• Abdomen
Insp : Distended, surgical wound is covered with gauze
Ausc : Normal bowel sound
Palp : Tender, liver & spleen hard to evaluate, epigastric pain -
Perc : Tympanic, Shifting dullnes -
• Extr : warm, CRT <2 secs, edema -/-
CHEST RADIOGRAPH
 RONTGEN INTERPRETATION
Rontgen components Interpretation
Identity Same
KV Normal adjusted
Symmetric Symmetrical
Diaphragma Normal
Mediastinum Normal
Sinus Costovertebrae Normal
Sinus Cardiophrenicus Normal
Bone Normal
Cor + CTR 37,2%
Pulmo Parenchym Infiltrates in the left lung paracardial

CONCLUSION : Suspect left bronchopneumonia

ECG
 ECG INTERPRETATION

ECG components Interpretation Value

Rhythm Sinus Rhythm Sinus Rhythm
Speed / HR (times/mnt) 110x/m 300/R-R’
Axis Normal Normal
Morphology P wave Normal Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,16 sec 0,12” – 0,20”
QRS complex duration 0,8 sec low voltage 0,05” – 0,11”``
extremity lead
ST segmen Normal Normal / Elevated / Depressed
T wave Normal cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION :Sinus Tachicardia, 110x/m, normoaxis
Abdominal CT – Scan with Contrast
30/11/2021
Conclusion :
• Suspected right wall mass distal to CBD suspected tuberculoma with
obstruction of EHBD and proximal IHBD.
• Impression of mesentery TB and lymphadentis TB with ascites.
• Suspect stone with sludge and dilated (DD. empyema) gallbladder.
• There was partial obstruction of the ureter at L3 level with bilateral
hydroureter and grade II hydronephrosis, and delayed left renal function.
• Basal lung TB is suspected, especially the left. Suspected hemangioma of
bodies T11 and L1.
 Lab Result (05/11/2021)
• Hb 11.5
• Na 122
• Leuko 20,300
• K 6.0
• Tro 118
• Cl 81
• Total bil 25.64
• PT 27.6/13.7
• Direct bil 22.29
• INR 2.14/1.01
• Ot pt 108/47
• APTT 47.6/31.6
• Ur cr 152/3.0
 Lab Result (06/11/2021)
• Leu 21.6
• RBG 92
• Hb 11.9
• D-Dim 7.3
• Tro 147
• CRP 48.00
• PT 22.7(13.7)
• Ot/Pr 139/55
• APTT 50.8(31.6)
• Ur/cr 169/3.2
• INR 1.73(1.01)
• Na/k/cl 121/6.7/84
• Bill tot/Bill dir 22.77/21.04
Lab Result (07/11/2021)
• Total bil 19.3
• Direct bil: 18.27
• RBG: 100
• Alb: 2.22
• Ur: 263
• Cr: 4.3
• Na: 135
• K: 6.58
• Cl: 97
 Care Plan
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
1. Septic shock ec Severe Norepinephrine 0.1mcg/kgbw/min BP > 90/60
cholangitis Meropenem 1gr/8hr H1 iv Stabilize Hemodynamic
Adequate antibiotics according to
cholangitis gr 3
Monitor general condition, vital sign, UO/
12hr
Blood culture + ST
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

2. Post cholecystostomy Adequate antibiotics according to Follow up treatment

H+1 ec severe cholangitis gr 3
cholangitis
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
3. Obstructive jaundice ec Monitor general condition, vital sign, UO/ Follow up treatment
susp tumor of the head 12hr
of the pancreas dd CBD
stones
 
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
4. Thrombocytopenia in Lactulose syr. 10ml/8 hour po Follow up treatment
liver disease
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
5. Hypercoagulable state Tranexamic acid 500mg/8hour po Follow up treatment
Vitamin K 1 amp/8 hours IV
Esomeprazole 8mg/hour IVSP
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention

6. AKI st. Failure dd acute Monitoring Urine Output /12hr Follow up treatment
on CKD ec Obstruction Consult Kidney Division , Supporting
nephropathy dd sepsis Hemodialisa
no Problem list Pharmacological and Non Output and Outcome
Pharmacological Intervention
7. Hyperkalemia without Novorapid 8 units in D40% 50ml/8 hours iv K 3.5-5.0
ECG changes Nebu Ventolin 4 resul/8 hours
Kalitake 3 x 1 sachet
Check Na, K, Cl control
 Conclusion
• Has been reported the case of a 55-year-old man who
was admitted to R. D. Kandou Hospital at ICU ward and
consulted to internal medicine from surgical department
with the chief complaint of Abdominal paint. After a
thorough history-taking, physical examination, and
laboratory-radiology workup, patient was diagnosed with
Septic shock ec Severe cholangitis, Post cholecystostomy
H+1 ec severe cholangitis, Obstructive jaundice ec susp
tumor of the head of the pancreas with CBD stones,
Thrombocytopenia in liver disease, Hypercoagulable
state, AKI dd Acute on CKD ec Obstructive nephropathy
dd Sepsis, Hyperkalemia without ECG changes
 Prognosis
• Ad vitam: dubia ad malam
• Ad functionam: dubia ad malam
• Ad sanationam: dubia ad malam