MORNING REPORT

Department of Internal
Medicine
1.12.2014

Ny Sukesih , syok sepsis

IDENTITY
Name : Ny. S
Age : 68 y.o
Sex : Female
Adress : Lamongan
Date : November, 3 rd 2014

ANAMNESIS

CHIEF COMPLAINT: weakness of the body

PRESENT ILLNESS HISTORY :

Weakness of the body since 12 hours before admission. Then family

of the patient bring her to the nurse, and said to be low blood
pressure with sistolic blood pressure 60 mmHg.
Vomiting -, nausea-, diarrhea-, fever-, cough-, shortness of breath.
The patient admitted to the RSML and her conciousness decreased.
Patient decreased her appetite since 2 days before admission.
Shortness of breath when the patient walked since 3 months ago.
Slept with 2 thin pillow without shortness of breath. Never woke up
because of abrupt shortness of breath

PAST ILLNESS HISTORY:

Hospitalized in intensive care unit because of AKI and
ARDS
COPD + DC FC II
History of DM denial
History of HT denial
History of 6 month treatment , her family said that
finished already
FAMILY ILLNESS HISTORY: HYSTORY OF MEDICINE : Social history :
Consumption of herbal medicine denial

PHYSICAL EXAMINATION
VITAL SIGN :
GCS
: 225 after loading 1000 cc
456 next 1 hours 225
BP
: 69/37mmHg after loading 1000
cc 112/67
PULSE RATE : 95 x / minutes
TEMP
RR

: 37oC
: 28x / minutes

Head and Neck :

Anemic (-/-), Icteric (-/-), Cyanosis (-/-),
Dyspneu (-),
LP +/+, pupil isokor 3 mm / 3 mm.
Pulmo:
Inspection :
symmetrical, retraction ( -/-), tachypneu +

Percussion : sonor
Auscultation: Lung Sounds : Peripheral
pulmonary vesicular field
Additional sound : crackles ( +/+ ) wheezing
(-)

Cor
Inspection : Voissure cardiac ( - ) , epigastric
pulsation ( - )
Auscultation : S1S2 single, murmur ( + )
pansistolik , gallop (-)

Abdomen :
I : flat, vena colateral (-),
P : soepel, met -, Liver and spleen not
palpable, tenderness P : shiffting dullness (-)
A: Bowel sound (+) Normal

Extremity :
dry, warm, red CRT < 2, Swelling (+) minimal, eritema
palmaris (-)

Clue and Cue

Female, 68 years old

Decreased of
conciousness
Hypotension
Tachypneu
Murmur pansistolik
Decreased of
appetite since 2
days ago
Dypsneu deffort

History of
hospitalized with
ARDS

Assesment
Susp. Cardiogenic shock DD Septic shock
Susp.
Susp. Decompensatio cordis

Planning Diagnose
CBC
LFT
RFT
Elektrolite

serum
Blood gas analize
Cardiac marker

Laboratorium

Diffcount 0/5/88/3/4 Be 3,0

Hematokrit 40,6%
Beecf 5,0
Hemoglobin 13,2 mg/dl cHCO3 31,7
LED 5/7 Clorida 94,5
Leukosit 18000 PCO2 68,2
Trombosit 102.000 pH 7,285
SGOT 2733 U/L PO2 171,1
SGPT 1380 U/L
SO2 99,3
GDA104 mg/dl
Kalium 4.5
Natrium 138
Clorida 100
Urea 120
Serum creatinin 3,8
CK 382
CKMB 13,63

Re-Assesment
Cardiogenic shock DD Septic shock with
MODS
Susp.Rheumatic Heart Disease
Ischemic heart disease NSTEMI

Planning Therapy

O2 NRM 10 lpm
IVFD Asering loading 1000 cc 1500cc/24hour
Attach cateter
Inj arixtra 1x1 sc
Inj ampicilin sulbactam 3x1
Clopidogrel loading 300 mg 1x1
Aspirin loading 300 mg 1x1

Consult internist

Monitoring
Vital signs
Complaint
Urine production

Prognosis

Dubia ad bonam

Education

Explaine to the family about the disease,

about its theraphy and intervention will be
done, and also about complication and
prognosis.