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DUTY REPORT

Friday, May 1st 2015

PHYSICIAN INCHARGE:
IB : dr. Intan, dr. Jaja, dr. Meli, dr. Rakhmi
II : dr. Vina, dr. Awan, dr. Arya, dr. Rizal
III : dr. Sri Sunarti, Sp.PD-KGer

Summary of Data Base


Female / 84yo / w.22
Chief complaint: general weakness
A 84 years old woman come to the ER because she felt general weakness since 5 days before
admission. Her body felt pegel- linu. When she was checked by a private doctor, the doctor
said her blood glucose was high (650 g/dl) and her blood pressure was 180/120 mmhg. She
also felt nausea but no vomiting, she felt full in her stomach easily. She has diabetes mellius
since 2 year ago, her blood glucose at that time was 350. She also has hypertension since 40
years ago. She didn’t routinely control for both of her disease. She sometimes felt shortness
of breath when she went to the bathroom with the help of her children. But she has never
been awaken in the middle of the night because of shortness of breath. And she still sleep
using one pillow.
History of past illness
She was hospitalized in Panti nirmala hospital last year, the diagnosis were diabetes mellitus
and swelling of the heart.
History of family
She didn’t really know about the medical history of her parent.
History of privation and social
She was a widow. And has 11 children.

Physical Examination

GCS 456 General Appearance which look moderately ill


BP 160/100 mmHg PR 98 tpm, iregular RR 20 tpm, Tax 36.1 0 C
strong
Looked Normoweight BW : 47kg
Head Anemic (-), Icteric (-),
Neck JVP R +3 cm H2O 300
Thorax Cor Ictus invisible, palpable at ICS VI 2 cm lateral of MCL RHM – sternal
dextra LHM –ictus cordis
S1 – S2 ireguler, murmur -
Lung Stem fremitus D = Sonor + + vv Rh - - Wh - -
S
++ vv - - - -
++ v v - - - -
Abdomen Flat, soft, bowel sound normal, liver span 8 cm, traube space is
tympani, shifting dullness -
Extermities Leg edema (-), pale skin (-)

Laboratory Finding

LAB RESULT NORMAL VALUE LAB RESULT NORMAL VALUE


Leukocyte 7.35 3,500- Sodium 137 136-145 mmol/l

10,000/µL
Hemoglobine 15.20 11.0-16.5 g/dl Potassium 2.94 3.5-5.0 mmol/L

MCV 80.20 80-97 µm3 Chloride 101 98-106 mmol/L


MCH 28.10 26.5-33.5 µm3
PCV 43.3 35-50% RBS 715 >200 mg/dL

Thrombocyte 337,000 150,000- Ureum 34.5 10-50 mg/dL


390,000/µl
SGOT 14 11-41U/L Creatinine 0.94 0.7-1.5 mg/dL

SGPT 11 10-41U/L

Urinalysis

Lab Value Lab Value


Urinalysis 10 x
SG 1.010 Epithelia 4.0
PH 6.5 Cylinder -
Leucocyte +3 Hyaline -
Nitrite - Granular -
Protein -
Glucose +3 40 x
Erythrocyte +1 Erythrocyte 2.7/hpf
Keton urine - Leukocyte 187.5/hpf
Urobilinogen - Crystal -
Bilirubin - Bacteria 7056.9 X 10 3

BGA
Value normal
PH 7.35 7,35-7,45
PCO2 33.0 35-45
PO2 71.1 80-100
HCO3 18.4 21-28
O2 saturation 93.3 > 95%
Base Excess -7.5 -3 until +3
Conclussion
7,35-7,45 metabolic acidosis fully compensated

ECG
 Sinus Arythmia, HR 88 tpm
 Frontal Axis : normal
 Horizontal Axis : counterclockwise rotation
 PR interval : 0.20”
 QRS complex : 0.08”
 QT interval : 0.24”
 Conclusion : Sinus arythmia with heart rate 88 tpm
CXR
AP position, asymmetric, strong KV, less inspiration, soft tissue and bone normal, intercostalspace
normal, trachea in the middle, left and right phrenico costalis angle was sharp , right and left
hemidiaphragm dome shape.
Lung : broncovascular was normal
Cor : site normal, shape normal, size CTR 60 %,
Conclusion : cardiomegaly

Cue Clue PL I.Dx P.Dx P.Th/ P.Mo P.Edu


Female/ 84 y.o/w. 22 1. Hyperglice 1.1 DM type II Inj. Levemir 0 – 8 IU SC Subj.
Ax: mic state VS.
General weakness GD1/2,
Diagnosed as DM since HbsAg
1 year ago
PE: BP 160/100
HR : 88 iregular
RR 20 tpm
Tax 36.1
CXR : cardiomegaly
Female/ 84 yo/ w.22 2. Asimptoma Urine Inf. Ciprofloxacin 2 x 200 mg Subject
Urinalysis: bacteriuria tic culture ive, VS
and leukosituria bacteriuria
Female/ 84 yo/ w.22 3.hypertensio Amlodipin 1 x 10 mg Subject
Ax: n st 2 ive
Dyspneu on effort.
Hypertension since 40
years ago
PE:
BP 160/100
HR : 88 iregular
RR 20 tpm
Tax 36.1
CXR : cardiomegaly
Female/ 84 yo/ w.22 4. HF st C Fc Hypertension control Subject
Ax: III Amlodipin 1x 10 mg ( as ive and
Dyspneu on effort. above) Vital
Hypertension since 40 sign
years ago
PE:
BP 160/100
HR : 88 iregular
RR 20 tpm
Tax 36.1
CXR : cardiomegaly
Female/ 84 yo/ w.22 5. Dyspepsia 5.1 DM Inj. Metoclopramide 3 x 10 Subject
Ax: syndrom gastropathy mg ive an
Nausea without p.o: omeprazole 2 x 20 mg vital
vomiting sign
Felt fullness in her
stomach.
History of DM since 1
year

Female/ 84 yo/ w.22 6. mild Diet DM 1700 kcal/day, with Subj.


LAB: hypokalemia extra kalium Vital
K: 2.94 sign
Female/ 84 yo/ w.22 7. iskemia ISDN 3x5 mg Subj.
Ax: miokard ASA 1x80 mg Vital
Dyspneu d’effort anterolateral Simvastatin 0-20 mg sign
PE:
Ictus invisible and
palpable at ICS VI 2 cm
lateral of MCL sinistra
ECG: T inversion on V3
– V6
CXR : cardiomegaly

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