MORNING REPORT

Saturday , May 19th 2012

Physician in charge
Jaga 1A : dr.indra (Cardio), dr. Eva, dr. ananto
Jaga 1B : dr. Sigit, dr Ryusda
Jaga 2: dr Ardhi
Jaga 3 : dr. Bogi, SpPD-KGEH

Mr Siti / 24 yo/ w 27
Chief Complain: Altered mental status
Chief complaint : Shortness of Breath ( Autoanamnesa )
Patient had suffered shortness of breath since 5 months before admission getting
worse since 3 weeks ago, relieved by rest. Patient usually sleep with 1-2 pillows.
he often woke up at night because SOB.
He had cough intermittently since 3 week, with no sputum no blood
Patient had intermittently suffered from fever since 3 weeks ago, releaved by
took medicine(parasetamol).
In last 3 month he felt decrease of her appetite and he ate only 4 or 5 spoon per
times, he ate 3 times daily
He had suffered nausea since 5 month ago and a day before admission he
complained vomiting 1 times contain fluid and residual food.
Patient presented from general weakness since 1 months before admission.
His body weight decrease 5 kgs in 5 months.
He was an active smoker more than 10 years, until now. usually had 10 bars of
ciggarete per day
He usually control to hospital because of general weakness and fever, he took 4
kind of medicine( Parasetamol, he had forgotten the rest of medicine)
He often took herbal medicine to relieve her muscle pain. He was a gardener

History of leg swelling.

History of hypertension (-)

History of DM: (-)

Physical Examination:
General appeareance

: looked moderately ill

GCS: 4-5-6

BP: 90/60 mmHg, PR: 110 bpm, regular

RR:24 tpm, Tax: 34.4 C
Head and Neck

: pale conjunctiva (+), sclera icteric (-)

JVP R+3 cmH2O ( 30 )

Thorax

: Heart ictus visible palpable at 2 cm MCL ICS VI (S)

S1/S2 single, no murmur( hard to evaluate) , LHM as
ictus, RHM as SL dextra, cardiac waist (-),
Pulmo symmetric

SF: D=S

Pr: s s

v v

Rh: - -

Wh - S s

v v

- -

- -

S s

bv v

+ -

Abdomen

:flat,epigastric tendernes, bowel sound normal, liver span 12

cm, traubes space tympani,

Extrimities

: edema - -, warm, pale (-), icteric (-)

- -

LABORATORY FINDING
Laboratory finding
Hb
Leucocyte
Thrombocyte
Hematocrite
MCV
MCH
RBG Ward/ RBG ER
Ureum
Creatinine
SGOT
SGPT
SE

Value
9,1
14,480
334
29.20
83.40
26
77
19.9
0.96
16
9

Normal range
11.0 - 16.5
3500 - 10000
150000 - 390000
35.0 50.0
>200
10-50
0.7 1.5
11 41
10 41

Natrium
Kalium
Chloride

134
4.08
113

136 145
3.5 5.0
98 106

BLOOD GAS ANALYSIS ( O2 4 lpm )

pH
pCO2
PO2
HCO3
O2 saturation arterial
Base excess
Conclussion

7.54
27.5
59.7
12.9
93.8
0.8
Alkalosis respiratory
partial compensated

N: 7.35 7.45
N: 35-45
N: 80-100
N: 21-28
N: >95
N: (-3) (+3)

URINALYSIS ( not yet perform )

CXR : AP position, symetris, KV enough, less inspiration, bone normal, soft

tissue thin,
right and left
\
costophrenico angle are sharp, right and left hemidiapragm are dome
shape.
Lung: infiltrate in middle and basal of lung dextra
thikening of hilus D and S
cor :site normal, cardiac waist (-), apex embedded, CTR 59%.
Conclussion : looked cardiomegaly (LVH, Dilatation of Left Atrium),
pneumonia
ECG : Sinus tachycardia HR 125bpm with LVH

Cue and
Clue
Male/24 yo
AX :
- Shortne
ss of
breath
- Dyspne

Problem
Initial
list
diagnose
1. HF st C 1.1
RHD
Fc III
sequele
1.2
Valvular
Heart

Planning
diagnose
Echocardi
ography

Planning
therapy
- -O2 4 lpm
NC
- Semifowle
r position
- IVFDv NS
LL

Planning
monitoring
Subjectif
BP
RR
Urine
production

u d
effort
PND.
Orthopn
oe
PE :
BP
90/60 ;
HR 110
bpm
JVP
R+3cm
H2O (
30)
Ictus at
2cm
MCL S
ICS VI
cardiac
waist (-)

Disease

- Soft Heart
diit 1500
kcal/day
- Inj
Furosemid
40 mg-0-0
post
poned
- Captopril
3x6,25
mg

- CXR:
looked
cardiomeg
aly (LVH,
Dilatation
of Left
Atrium),
pneumoni
a
- ECG
Sinus
tachyca
rdia HR
125bpm
with LVH
Male/24 yo
AX :
- Shortne
ss of
breath
- Dyspne
u d
effort
- PND.
- Orthopn
oe
- Fever
- Cough
- PE :
- Tax:

Lung
Infection

2.1
Pneumonia
CAP

Sputum
culture
and
sensitivit
y test

- Inj
Ceftriaxone
2x1 gr (IV)

VS
Culture
result

34,4
- BP
90/60 ;
HR 110
bpm
RR
24tpm
- JVP
R+3cm
H2O (
30)
- Ictus at
2cm
MCL S
ICS VI
cardiac
waist (-)
- Rhonki
in basal
of the
left lung
- CXR:
looked
cardiomeg
aly (LVH,
Dilatation
of Left
Atrium),
pneumoni
a
- ECG
Sinus
tachyca
rdia HR
125bpm
with LVH
Leucocyte
14480
Port Score
89
Female/55
yo
Nausea
Vomiting
Epigastric
tenderness
History
took
herbal
medicine

3.
Dyspepsia
syndrome

3.1 PUD
3.2 gastritis
acute

Endoscop
y

Inj ranitidine
2x 50 mg
Inj
metoclopra
mide 3x 10
mg

Subj

THANK YOU