dr.

Satiti

MORNING REPORT
Thursday, 2nd June 2022

Physician in charge
I : dr. Liku, dr. Kamal, dr. Patan, dr. Naya
II Consultation : dr. Satiti
II HCU : dr. Tomi
II Incovit : dr. Alid
II IGD : dr. Firman, dr. Mazen
II IGD Incovit : dr. Heru
Chief on duty : dr. Tama
Consultant on duty : dr. Laksmi Sasiarini, SpPD-KEMD
Facilitator : dr. Syifa Mustika, SpPD-KGEH
 Summary of Database

Mrs. TS/ 60 y.o./ Ward 26

Alloanamnesa
Chief Complaint: Decrease of Consciousness
History of Present Illness:
• Sudden decrease of consciousness since last night, the patient tend to sleep and had
incoherent speech.
• History of black tarry stool since 1 day previously, this is the first time she had this
complaint. History of ground coffee vomit and distention of abdomen was denied.
• Her appetite was decreasing, her body weight tend to decreased approximately 12 kgs
within the past 2 years. History of fever and seizure before was denied.
• She was hospitalized in Saiful Anwar hospital 2 month ago due to pneumonia and
hypoalbuminemia.
• History of Diabetes and Hypertension was denied
• History of multiparter sex, using of injected drugs, or narcotics was denied
• Her daily activities was depend on the helper (eating, showering, or walking)
 Summary of Database

Past Medical History:

There is no remarkable past medical history before

Family History:
There is no family that have similar symptom before. The history of autoimmune nor
malignancy in the family was also denied.

Social History:
She work as a housewife, and lived with her husband and child

Review of System:
The Urine production was normal
 Physical Examination
General appearance looked moderately ill Sat O2 99% in Room Air
GCS 456 Weight 45 kg, Height 160 cm (BMI 18.75 kg/m²)
BP 107/82 mmHg PR 104 bpm regular strong RR 20 tpm Tax 36,0 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+0 cmH20
Chest Symmetrical, retraction (-)
Sonor | Sonor Vesicular | Vesicular Rhonkhi : -|- Wheezing : - | -

Sonor | Sonor Vesicular | Vesicular -|- -

Lung |-
Sonor | Sonor Vesicular | Vesicular -|- -
|-
Ictus visible, palpable at ICS V MCL S
Cardio LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Abdomen Liver/ unpalpable, liver span 8 cm
Lien/ Traube space tympany

Extremities Edema (-), Pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-), palmar erythema (-)
5|5

Rectal Toucher Mucosa Licin, Melena (-)

 Laboratory Findings
LAB VALUE NORMAL LAB VALUE NORMAL
Hemoglobine 9,4 11,4 - 15,1 g/dl Ureum 32,5 20-40 mg/dL
Leucocyte 2.750 4.700 – 11.300 /µL Creatinine 0,59 <1,2 mg/dL
HCT 26,8 38 - 42% GFR 100,32 >90 mL/min/1.73 m2
Thrombocyte 256.000 142.000 – 424.000 /µL Natrium 134 136-145 mmol/L
MCV 92,7 80-93 fl Kalium 3,46 3,5-5,0 mmol/L
MCH 32,5 27-31 pg Chlorida 109 98-106 mmol/L
Eo/Bas/Neu/ 0,4/ 0/ 57/ 0-4/0-1/51-67/ PPT 13,9 9.3-11.4 detik
Limf/Mon 31,3/ 11,3 25-33/2-5 APTT 31,2 24.8-34.4
SGOT 143 0-40 U/L INR 1,36 <1,5
SGPT 114 0-41 U/L RBS 101 < 200 mg/dl
Kalsium 7,4 7,6 – 11,0 mg/dL Pro Calcitonin 1,19 <0.5 ng/mL
Phospor 3 2,7 – 4,5 mg/dL CRP 3,28
Bilirubin Total 1,79
Bilirubin Direct 1,44
Bilirubin Indirect 0,35
 Urinalysis
LAB VALUE LAB VALUE
Turbidity 10 x
Colour Epithelia
pH Cylinder
SG Hyaline
Glucose Granular
Protein Leukocyte 0,8
Urine ketone 1+ Erythrocyte 1,3
Urobilinogen 66 40 x
Bilirubin 2+ Erythrocyte
Leucocyte Eumorfik
Nitrite + Dysmorfic
Darah Leukocyte
Jamur Crystal
Bacteria 69131,8
 Blood Gas Analysis
Lab Value Normal Value
pH 7,49 7,35 - 7,45 mmHg
pCO2 24,9 35 – 45 mmHg
pO2 97,9 80 – 100 mmHg
Bikarbonat (HCO3) 19 21 – 28 mmHg
Base Excess (BE) -4,7 (-3) – (+3)
P/F ratio 463 (not ARDS)

Conclusion: alkalosis respiratory compensated with metabolic Acidosis

Chest X-Ray
 Chest X-Ray
Thorax AP (less inspiration)
Cor : Size, shape, and site normal
Aorta : No elongation, dilatation, calsification (+)
Trachea : in the middle
Pulmo : Normal vascular pattern. Hilus D/S normal. No infiltrate/
cavity/nodule shown
Costophrenic Angle : Sharp
Hemidiaphragm D/S : Dome shaped
Sceleton : No osteolytic/osteoblastic/ fracture line shown
Soft tissue : Normal

Conclusion
Rotated position, aortic sclerosis
 ELECTROCARDIOGRAPHY
• Sinus Rhythm 121 bpm regular
• Frontal Axis : normal
• Horizontal Axis : CCWR
• P wave : 0.10 s
• PR interval : 0.12 s
• QRS complex : 0,07 s
• Q wave : patology Q wave (-)
• QT interval : 0.36 s
• ST segment : isoelectric
• T waves : T Inverted lead V1-V3

Conclusion:
Sinus tachycardia 121 bpm, CCWR, T Inverted lead V1-V3
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
[Name/Age/Ward] Non Pharmacology
Subjective

Objective Pharmacology

Laboratory