MORNING REPORT

Friday, July 8th 2011 PHYSICIAN INCHARGE: IA : dr. Rusyda, dr. Meci, dr. Supono IB : dr. Amel, dr. Vindriya II : dr. Maya III : dr. Sri Sunarti, SpPD

Summary of Data Base

Mrs. R/ 25 y.o/w 26
Chief complained : Fever Patient suffered from fever since 10 days before admission, abruptly onset, especially in the morning. She never experienced fever like this before. It was accompanied with cough and whitish sputum, discomfortness in her throat and nasal congestion. She also had nausea and decreased of appetite. Theres no pain during micturition, and her urine colour is dark yellowish. She had no defecation for 3 days. Theres left lower abdominal tenderness. Shes pregnant, duration 24-26 weeks. Theres no bleeding. She had controlled to obstetrician 7 days ago, and given paratusin and xyrex. But she didnt getting better, so she controlled to another obstetrician then she

Physical examination
BP = 100/70 mmHg PR = 120 bpm RR = 30 tpm GCS 456 Gravida Tax : 39.6 0C GA looked moderately ill Head Neck Thorax cor Anemic -

Halitosis Coated tongue, T2/T2 hiperemis

Cervical limph enlargement Ictus invisible palpable at ICS V MCL S RHM SL D, LHM ~ ictus

S1S2 single
lung I:Simetric, P: SF D = S S S v v Rh - S S vv S S vv Abdomen --Wh - ---

Distended, soft, BS + normal, epigastric tenderness, ballotement + liver span 8 cm & troube space tympani, TFU : umbilikus p.xyphoideus

Extermities

Warm acral

Laboratory finding
Lab Value Lab Value

Leucocyte
Hb MCV MCH PCV

5300
8 93 34 22

3500;10000/L
11,0-16,5g/dl 80-97H um3 26,5-33,5H pg 35-50%

Na
K Cl SGOT SGPT

130
2.92 101 116 36

136-145Mmol / L
3,5-5,0Mmol / L 98-106Mmol / L 11-41U/L 10-41U/L

Trombo

156000

150000390000/L

Albumin

2.60

3.5- 5 g/dL

RBS Ureum Creatinine

86 12.0 0.45

(<200)mg/dL 10-50mg/dL 0,7-1,5mg/dL

Ig M Salmonella ESR

5+ 65

Laboratory Finding continued...

Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin
1.015 6.5 3+ 3+ -

Value

Lab 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x

Value
+ -

Eritrosit
4+ 4+ +

0-2/hpf 8-10/hpf +

Leukocyte Crystal Bacteria

CUE AND CLUE

PL

IDx

PDx

PLANNING THERAPY

PMo

Female,25 yo -Gravida 24-26 weeks -First pregnant

1. G1P0 Ab0 24-26 weeks Blood pneumon culture Urine ia CAP culture 2.2 2.1 salmonell osis 2.3 UTI

High calorie high protein diet

VS Subj Fetal heart sound

Female,25 yo -Acute intermittent fever -Dry cough -Nausea/vomiting -Anorexia -Coated tongue -Pharyngitis -Salmonella IgM 5+ -ESR 65 -Leucocyturia -SGOT/SGPT 116/36

2. AFI day 10

Inj Ceftriaxone 2x 1 gr IV Inj metoclopramide 3x 10 mg PO Omeprazole 2x 20 mg PO Paracetamol 3x 500 mg Surface cooling

VS Subj CBC SGOT/ SGPT

CUE AND CLUE

PL

IDx

PDx

PLANNING THERAPY

PMo

Female,25 yo Gravida

3. Anemia 3.1 due to NN no 1

Hb 8.0
MCV 93 MCH 34 Female,25 yo SGOT/SGPT 4.

3.2 acute
blood loss

Reticulo High calorie high cyte protein diet count Vit B6/B12 3 x 1 tab Folic acid 1 x 3 tab

VS Subje

ctive

4.1 reactive

Increased hepatitis

116/36

transamin 4.2 hepatitis

ase viral infection

HBs Ag Anti HCV

Confrim diagnose

VS Subje

ctive
SGOT /SGPT

Summary of Data Base

Mrs. S/ 52 y.o/W28 Chief complained : decreased of consciousness Patient had decreased of consciousness gradually onset since 3 hours before admission. She was found had slurred speech by her daughter. Then she was given a glass of syrup, and after that she was awaken. A few hours then she got slurred speech again. Then her family brought her to RSSA. She had Diabetes for 6 years, known accidentally when she admitted in private hospital due to stroke in 6 years ago. She had frequent night micturition 2-3x.night. She got Amaryl M (Glimepiride 2mg+ Metformin 500mg) twice daily. Her family restrict her meal, she was only given 4 tablespoon of meal each time. The last time she took medication is after she had her lunch. She had long standing hypertension for 30 years. She had wound in her right foot, ruptured blister since a month ago.

Physical examination
BP= 160/100mmHg PR = 72 bpm RR = 22 tpm GCS 456 Tax: 35.5 C GA looked moderately ill Head/Neck Anemic -

Thorax cor

Ictus invisible palpable at ICS VI MCL S

RHM SL D, LHM~ictus S1 S2 single, mur mur -

lung

I:Simetric, P: SF D = S S S v v Rh - S S vv S S vv

Wh - -

Abdomen

flat,BS + normal, epigastric tenderness liver span 8 cm, troube space timpany.

Extermities

Ruptured blister clear border, hyperpigmentation, eritema -, edema -

Laboratory finding
Lab Value 3500;10000/L 11,0-16,5g/dl 80-97H um3 26,5-33,5H pg 35-50% 150000390000/L RBS Ureum 153 39.0 (<200)mg/dL 10-50mg/dL 0,7-1,5mg/dL Lab Na K Cl Albumin SGOT SGPT Value 138 3.05 105 2.96 17 14 11-41U/L 10-41U/L 136-145Mmol / L 3,5-5,0Mmol / L 98-106Mmol / L Leucocyte 9600 Hb MCV MCH PCV Trombo 12.3 90 31 35.8 253000

Creatinine 0.78

Chest X ray
CXR : AP position, KV too strong, asymetric, trachea in the middle, bone and soft tissue normal, Phrenico costalis angle on Right sharp and Left covered by cardiac image, Hemidiaphragm D dome shape and S covered by cardiac image, CTR 63%, boot shaped Conclusion : cardiomegaly

CUE AND CLUE

PL

IDx

PDx

PLANNING THERAPY

PMo

Female, 52 yo
DOC Low intake History took oral anti diabetic drug

1. (post)
Hypoglycemi a

1.1 drug
induced (glimepirid e) 1.2 low

Free diet IVFD D 10% 10 tpm

VS
Subjectiv e RBG/4 hr

Long standing DM type 2

RBG 29 mg/dl 153 mg/dl -Female, 52 yo -Long standing DM type 2 -Overweight -Decreased of BW -Nocturia -History took oral anti diabetic drug -History of CVA ICH -Long standing hypertension -Last RBG 153 mg/dl 2. DM type 2 overweight

intake

Fundusc opy

Diabetic diet 1700 kcal/day low salt (postponed)

VS Subjectiv e FBG PPBG

CUE AND CLUE

Female, 52 yo Wound in her right foot Long standing DM type 2 RBG 153 mg/dl -Female, 52 yo -Long standing DM type 2 -Long standing HT -History of CVA ICH -BP 160/100 mmHg -RBG 135 mg/dL -Female, 52 yo -Long standing DM type 2 for 6 years -Long standing HT for 30 years -History of CVA ICH

PL
3. Ulcus diabeticum W1

IDx

PDx

PLANNING THERAPY
Wound toilette Inj Ceftriaxone 2x 1 g IV

PMo

VS Subjectiv e

4. CVA sequelle

PO. Captopril 3x 12,5 mg PO. Hct 0-25mg-0 PO. Simvastatin 0-10 mg

VS Subjectiv e

5. Hypertensio n st 2 on tx

5.1 essential Hypertensi on 5.2 renovascul ar HT

As above

VS Subjectiv e Ur/Cr SE

Summary of Data Base

Mr. MB/ 56 y.o/W26 Chief complained : decreased of consciousness neglected patient

Physical examination
BP = 90/60 mmHg PR = 82 bpm RR = 24 tpm Tax 36.8 C
GA looked moderatey ill Head Scleral icteric GCS 446, look confused, restless

Neck
Thorax cor

JVP R + 2 cm 450

Neck limph enlargement

Tattoo in chest wall multiple, skin abration in back mid diagonal Ictus invisible unpalpable RHM SL D, LHM ICS V MCL S

S1 S2 single, mur mur lung I:Simetric, P: SF D = S S S v v Rh - D = S S S v bv D = S S S v bv Abdomen -+ -+ Wh - ---

Flat, BS + N, abdominal tenderness -,

liver span 4 cm , troube space dullness

Extermities GE Dry skin, eritema palmaris -, oedem Catheter inserted , urine dark yellowish, RT: melena -

Lab

Value Lab Laboratory finding 3500;10000/L 11,0-16,5g/dl 80-97H um3 26,5-33,5H pg 35-50% 150000390000/L Na K Cl Albumin SGOT SGPT

Value 143 4.6 102 2.45 124 70 136-145Mmol / L 3,5-5,0Mmol / L 98-106Mmol / L 3,5-5,0 g/dL 11-41U/L 10-41U/L

Leucocyte 6200 Hb MCV MCH PCV Trombo 10.8 89 30.9 30.9 97000

RBS Ureum

110 27.9

(<200)mg/dL 10-50mg/dL 0,7-1,5mg/dL C: 12.3

Bilrubin tital Bilrubin direct Bilirubin indirect aPTT

3.33 0.98 2.35 36.1 C: 26.4

Creatinine 0.92 PPT 17.4

Laboratory Finding continued...

Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin
1.010 8 -

Value

Lab 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x

Value
+ -

Eritrosit
-

0-1hpf 0-1/hpf -

Leukocyte Crystal Bacteria

Chest X ray
CXR : AP position, KV too strong, asymetric, enough inspiration, trachea in the middle, bone and soft tissue normal, Phrenico costalis angle on Right and Left blunt, Hemidiaphragm D and S dome shape, CTR hard 58%, site normal, Conclusion : Normal

ECG
Sinus Rhythm, HR 60 x/mnt PR Interval :0,12 QRS Interval : 0,06 QT Interval : 0,48 Frontal axis : normal Horizontal axis : counterclockwise rotation T inverted asymmetric in V1 Conclusion: sinus bradicardia

Summary of Data Base

Mr. M/ 31 y.o/w 27
Chief complained : Fever Patient suffered from fever since 6 days before admission, abruptly onset, especially in the morning. She never experienced fever like this before. Theres no nose bleeding and gum bleeding. It was accompanied with nausea and decreased of appetite. There diarrhea since 4 days, frequency 3-5x/day but already stopped since she had medication from general practitioner nearby.

Physical examination
BP = 110/80 mmHg PR = 84 bpm RR = 24 tpm GCS 456 Halitosis Tax : 37.1 0C GA looked moderately ill Head Neck Thorax cor Anemic Pthechiae + Ictus invisible unpalpable RHM SL D, LHM ~ ICS V MCL S

S1S2 single, no additional heart sound

lung I:Simetric, P: SF D = S S S v v Rh - S S vv S S vv Abdomen --Wh - ---

Ptechiae +, soft, BS + normal, epigastric tenderness+ liver span 10 cm & troube space tympani

Extermities

Warm acral , ptechiae +

Laboratory finding
Lab
Leucocyte Hb PCV Trombo

Value
4.830 17,0 51,5 13000 3500;10000/L 11,0-16,5g/dl 35-50% 150000-390000/L

Lab

Value
3 55 39 6 Mm/hour

LED Eosinofil Basofil Stab Segment Lymphocyte Monocyte

Chest X ray
CXR : AP position, KV too strong, asymetric, enough inspiration, trachea in the middle, bone and soft tissue normal, Phrenico costalis angle on Right and Left blunt, Hemidiaphragm D and S dome shape, CTR hard 58%, site normal, Conclusion : Normal

CUE AND CLUE

PL

IDx

PDx

PLANNING THERAPY

PMo

Male,31 yo
-Acute fever,abruptly onset -Ptechiae

-Nausea/vomiting
-Trombocytopenia

SGOT/ High calorie high SGPT protein diet tromboc 1.2 Albumin IVFD RA 1 liter ytopenia rickettsiosis continued with day 6 1.3 other RL 20 dpm arboviral Inj ranitidine 2x infection 50 mg Inj metoclopramide 3x 10 mg Surface cooling 1. AFI 1.1 DHF

VS
Subj Fetal heart

sound

Thank you