MORNING REPORT

C5 ward
October, 20th 2021
 Patient Identity
• Name : Mrs. NSS
• Age : 68 years old
• Sex : Female
• Occupation : House Wife
• Education : Senior High School
A 68 year-old Female was admitted to R.D.
Kandou Hospital at C5 ward on

October, 20th 2021

Chief complaint: Shortness of breath

 Present Medical History
• Shortness of breath less more for the last 1 month and worsened for the last 1
week.
• Initially, the patient has diagnosed with lung TB and started consumed category
1 anti tuberculosis drug, but after taking these drug on the early month,
appeared red bump on all over body with itchy. But, when the drugs has
stopped the complaint gets better
• The Patient has not taken anti tuberculosis drugs for less more 2 weeks.
• Now the patient has complained shortness of breath
• Epigastric pain (+), nausea (-), vomit (-), the pain felt burning
• General weakness, decreased of body weight , night sweat and decreased of
body weight 3 kgs in 1 month
• Urinating was normal with volume 1000-1500cc
• Defecation was normal, but the patient has not defecation since 2 days ago
 Past Medical History

• History of hypertension, diabetes mellitus, heart

disease were denied
 Family History
• None experienced the same illness
 Physical Examination
• GC: Generally ill . Sens : Compos mentis
• Vital sign : BP: 106/74 mmHg, PR 75x/m, RR 24x/m, T
36.5 oC SpO2 96% room air, 100% NRM 10 lpm
• Head : conj. anemic (-), scl. icteric(-)
• Neck : JVP 5+2 cm H2O, lymph nodes enlargement (-)
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC not 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 L decreased
Perc :Sonor
Ausc : Vesicular left decreased, ronchi -/- , wheezing -/-
• Abdomen
Insp : Flat
Ausc : Normal bowel sound
Palp : Tender, no liver & spleen enlargement, epigastric pain +
Perc : Tympanic
• Extr : warm, CRT <2 secs, edema -/-,
• RT : TSA fixed, empty ampula, mass -, melenic stool -
CHEST RADIOGRAPH
 RONTGEN INTERPRETATION
Rontgen components Interpretation
Identity Same
KV Normal adjusted
Symmetric Symmetrical
Diaphragma Normal
Mediastinum Normal
Sinus Costovertebrae Sharp
Sinus Cardiophrenicus sharp
Bone Intact
Cor + CTR Shape and size enlargement
Pulmo Parenchym Fibro infiltrate on both lung

CONCLUSION : Active lung tuberculosis, cardiomegaly

ECG
 ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus rhythm Sinus Rhythm
Speed / HR (times/mnt) 100 bpm 300/R-R’
Axis Normal Normal
Morphology P wave Normal Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,20 sec 0,12” – 0,20”
QRS complex duration 0,10 sec 0,05” – 0,11”``
ST segmen Normal Normal / Elevated / Depressed
QT Interval Normal cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION :Sinus rhythm, 100x/minute, Normoaxis
 Lab Result (20/10/2021)
• WBC 9.5 • INR 1.16/1.11
• Eri 5.98 • APTT 29.4/38.1
• Hb 14.8 • AST 26
• Ht 46.7 • ALT 11
• T 281 • Ur 97
• MCH 24.7 • Cr 1.0
• MCHC 31.7 • Na 133
• MCV 78.1 • K 2.7
• Diffcount 0/0/8/70/18/4 • Clorida 94
• RGB 106
 Natrium Correction

– Na deficit: (140-133)x0.6x50 = 210 meq

– Na daily: 2-3 meq/kgBB = 100-150 meq
– Total Na = 310 – 360 meq

– Max Na / day = 8x0.6x50 = 240 meq

– NaCl 0.9% = 240/154 *1000 = 1,558 ml/day

– Duration = 360/240 x 24 hours = 36 hours

– Osmolality = 2 x 133+ (106/18)+ (97/6) =282.1
 Kalium Correction

– K deficit: (4-2.7)x0.4x50= 26 meq

– K daily: 1X50= 50 meq
– K Correction = 76 meq
 Care Plan

no Problem list Pharmacological and Non Output and Outcome

Pharmacological Intervention

1 Drop out anti Lung N asetilsistein 200 mg/8 hours PO Cough (-)
tuberculosis drug
 Care Plan

no Problem list Pharmacological and Non Output and Outcome

Pharmacological Intervention

2. Suspect anti Consult allergy and immunology division Diagnostic

tuberculosis drug
allergy
 Care Plan

no Problem list Pharmacological and Non Output and Outcome

Pharmacological Intervention

3. Dyspepsia syndrome Lansoprazole 30 mg/12 hours PO Epigastric pain (-)

Sucralfat 10cc/8 hours PO VAS 1-3
Nausea (-) Vomit (-)
Sindroma Dispepsia
Sindroma dispepsia
Penyebab Dispepsia
Sindroma dispepsia
 Definisi
• Dispepsia adalah kumpulan gejala nyeri
atau rasa tidak enak di abdomen atas
yang episodik atau persisten, kronik atau
rekuren yang disebabkan oleh berbagai
faktor
• Dikenal juga sebagai overlap syndromes
(sindroma tumpang tindih)
Tabel 1. Diagnosis Banding Penyebab Dispepsia
Kategori diagnostik Prevalensi
Dispepsia fungsional Sampai 60 %
Dispepsia karena penyakit struktural atau biokimia
Tukak peptik 15 – 25 %
Esofagitis refluks 5 – 15 %
Kanker lambung atau esofagus <2%
Penyakit saluran bilier Jarang
Gastroparesis Jarang
Pankreatitis Jarang
Malabsorbsi karbohidrate (laktose, sorbitol, fruktose, mannitol) Jarang
Obat – obatan Jarang
Penyakit infiltratif lambung (Penyakit Crohn, sarcoidosis) Jarang
Gangguan metabolik (hiperkalsemia, hiperkalemia) Jarang
Hepatoma Jarang
Penyakit usus iskemik Jarang
Penyakit sistemik (diabetes melitus, penyakit tiroid, and Jarang
paratiroid, penyakit jaringan ikat)
Parasit usus (Giardia, Strongyloides) Jarang
Kanker abdomen, terutama kanker pankreas Jarang
 Patogenesis
• Ketidak seimbangan antara faktor agresif
dan faktor defensif
• Bila faktor agresif lebih kuat atau faktor
defensif lebih lemah maka akan terjadi
kerusakan mukosa gaster
 PATOGENESIS kerusakan Mukosa Gaster

Faktor agresif Faktor defensif

Asam gaster Aliran darah mukosa
Pepsin Permukaan sel epitel
Refluks empedu Protaglandin
Nikotin Fosfolipid / surfaktan
OAINS Mukus
Kortikosteroid Bikarbonat
Helicobacter pylori Motilitas
Radikal bebas Impermeabilitas mukosa
Stres Terhadap ion H
Regulasi pH Intraseluler
Faktor pertumbuhan
 Gejala Klinis
• Keluhan / gejala sangat bervariasi
• Bila nyeri ulu hati yang dominan disebut (Dyspepsia
Like Ulcer)
• Bila kembung, mual, cepat kenyang yang sering
dilkeluhkan, ini disebut (Dyspepsia like dismotility)
• Bila tidak ada keluhan yang dominan, dikategorikan
sebagai Dyspepsia non spesifik
• Dyspepsia like reflux (Tidak masuk lagi dalam kriteria
ROMA II)
• Alarm simptom
 Care Plan

no Problem list Pharmacological and Non Output and Outcome

Pharmacological Intervention

4 Hypokalemia IVFD NaCl 0.9% + KCl 25 meq K 3.5 -5.3

Check Na, K, Cl control
Hipokalemia
 Care Plan

no Problem list Pharmacological and Non Output and Outcome

Pharmacological Intervention

5 Hyponatremia IVFD NaCl 0.9% Na 135-153

hypovolemia Sodium caps 1 tab/8 hours PO
Check Na, K, Cl control
Hiponatremia
 Conclusion
• Has been reported the case of a 68-year-old female who
was admitted to R. D. Kandou Hospital at C5 ward with
the chief complaint of Shortness of breath. After a
thorough history-taking, physical examination, and
laboratory-radiology workup, patient was diagnosed with
Drop out anti tuberculosis drug, suspect anti tuberculosis
drug allergy, dyspepsia syndrome, hypokalemia and
hyponatremia hypovolemia
 Prognosis
• Ad vitam: dubia ad bonam
• Ad functionam: dubia
• Ad sanationam: dubia ad bonam
Thank You