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MORNING REPORT

Friday, October 14th 2011

PHYSICIAN INCHARGE:

IA

: dr. Ade, dr. Herwindo, dr. Aditya, dr. Widyo

IB

: dr. Rusyda, dr. Eric

II

: dr. Rofika

III

: dr. Shinta Octya, SpPD

Summary of Data Base

Mr. moersiadi /74 y.o/W 24b Chief Complain : decrease of consciousness Patient became unconscious 12 hours before he

arrived at RSSA. He also had excessive sweating. 1

hour before unconscious, he injected insulin 22iu but he forgot to eat after that.

He has been diagnosed as diabetes since 2008. he

routinely

controlled

to

out

patient

of

department and got insulin before meal.

24iu

at

night

endocrine and 22iu

Summary of Data Base

He

also said

that

his blood

pressure

usually

was

150/

Patient sometime had cough since 1 month ago. He

was diagnosed having TBC in 2010, and already

finished his treatment for 6 month. The last CXR (29

dec 2010) showed bekas KP”. He denied about decreased of body weight. He did not smoke.

Physical examination

BP = 150/90mmHg

PR = 84 bpm

RR = 18 tpm

   

General appearance looked moderately ill

GCS 111456

 

Looked normoweight

   

Head

Anemic -

Icteric -

 

Neck

JVP R + 0 cmH 2 O; 30°

   

Thorax:

Heart:

Ictus invisible and palpable at ICS V MCL sinistra LHM: ictus

 

RHM: SL

S1, S2 single with no murmur

 
 

Lung:

Symmetric, SF D = S

s s

v

v

Rh

-

-

Wh - -

 

s s

v

v

-

-

- -

s s

v

v

-

-

- -

Abdomen

Soefl, liver span 8 cm, troube space tympani, bowel sound

normal

Extremities

Warm

Laboratory finding

Lab

Value

Lab

Value

Leukocyte

13,200

3.500-10.000/µL

Natrium

152

136-145 mmol / L

Kalium

3.91

3,5-5,0 mmol / L

Haemoglobine

14.8

11,0-16,5 g/dl

Chlorida

111

98-106 mmol / L

RBS

  • 15

PCV

45

35-50%

SGOT

 
  • 27 11-41U/L

Trombocyte

267,000

150.000-

SGPT

 
  • 18 10-41U/L

390.000/µL

Ureum

40.6

10-50 mg/dL

Alb

4.17

 

Creatinine

0.87

0,7-1,5 mg/dL

CPK

200

CKMB

27

Trop I

- (0.1)

ECG (14/10/2011)

Sinus rhythm, heart rate 68 bpm

Frontal Axis

: Normal

Horizontal Axis PR interval

: Normal : 0.12''

QRS complex

: 0.04”

QT interval

: 0.32”

Conclusion : Sinus rhythm with heart rate 68 bpm

CXR 141011

CXR 141011

CXR (14/10/2011)

AP position, asymmetric Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and hemidiaphragm are dome-shape Aortic knot +

• • Lung: thickening of hillus D/S, fibroinfiltrat in medial area of the lung, infiltrat in apex Cor site, shape are normal, with CTR 46%

Conclusion: KP active

Male/74 yo

1.

Hipogli

1.1 due to

D40% 50mL (iv)

Subjective

Unconscious 12 hours

cemia

insulin

IVFD NS 20dpm

VS

before admission Excessive sweating Injected insulin 22iu and did not eat 1 hour before unconscious Had been diagnosed diabetes since 3 years ago

state

Free diet Stop insulin

GCS RBG 15 minutes after correction and serial

got insulin

GCS 111 456 BP: 150/90 PR: 84 RR: 18

RBG: 15 Leukocyte 13,200

Male/74 yo

2.

DM type

Insulin postponed

FBG

Had been diagnosed

2 normo

 

2hppBG

diabetes since 3

weight on

years ago got insulin as his treatment

insulin

GCS 111 456 BP: 150/90 PR: 84 RR: 18

 

RBG: 15 Leukocyte 13,200

Male, 74yo

3.Hyperten

3.1

Autonomic

Fundusco

Low salt diet

Subjective

Had history having

sion stage

neuropathy due

py

BP

blood pressure 150/ ..

1

to DM

type 2

Lipid

Without theraphy

3.2

profile

atherosclerosis

BP 150/90

HT

Male, 74 yo

4.

Chronic

4.1

KP active

sputum

Confirmed diagnosed

Subjective

Chronic cough

lung inf

 

culture

VS

Diagnosed as TBC 1

AFB

year ago

SPS

CXR active KP

Thank you