dr.

Deddy-PPDS IPD
MORNING REPORT

October 24th 2012

PHYSICIANS INCHARGE:
IA : dr. Deddy, dr. Lya , dr. Ike (Cardio)
IB : dr. RifaI, dr. Ade
II : dr. Satriyo
III : dr. Gadis Nurlaela, SpPD
MODERATOR : dr. Ninik Burhan, SpPD-KPTI
 Summary of Data Base
Female /24 y.0/w. 26

Chief complain: decrease off consciousness

Patient suffered from decrease off consciousness since 6 hours before

admission, gradually. At the beginning she could talk and then she couldnt
talk for along while. Shortness off breath since 1 day before admission.

She complained about epigastric pain radiated to the back .

She complained about body weakness since 1 week before

admission. Body weight loss about 4 kg in the last 3 months. She had family
problem that cause stress.

Family history : DM (+) her aunt and her grand mother

HT (+) her mother

History of past illness :

-She got operated to take pus from mammae dextra in August 2012

- Gastritis (+)

- DM and HT unknown.
 Physical examination
BP = 110/70 mmHg PR = 112 bpm RR = 28 tpm Tax : 37.4C
Kusmaul type
General appearance looked severely ill GCS 334

Chest Heart: Ictus invisible, palpable at MCL S ICS 5 Sinistra

RHM ~ SLD, LHM ~ ictus
S1-S2 single, murmur (-)
Pulmo: Simetris, ves ves Rh Rh Wh Wh
ves ves Rh Rh Wh Wh
ves ves Rh Rh Wh Wh
Abdomen Soefl, liver span 10 cm, traubes space tympany
Extremity Oedema - - , warm acral - -
- - - -
Lab Value (Normal) Lab Value (Normal)

Leukocyte 37.080 3.500-10.000/L Natrium 126 136-145 mmol/L

lymphocyte

Haemoglobine 10,90 11,0-16,5 g/dl Kalium 4.7 3,5-5,0 mmol/L

PCV 33.50 35-50% Chlorida 94 98-106 mmol/L

Trombocyte 694000 150.000- RBS 653 < 200 mg/dl

390.000/L
MCV 77.00 80-96 fl Ureum 56.70 10-50 mg/dL
MCH 25.10 26,5-33,5 pg Creatinine 0,7-1,5 mg/dL

SGOT 20 11-41U/L 0sm 280.3

SGPT 14 10-41U/L Urine prod 60 cc/h
Neu/Lim/Mo 69/10/12 Blood smear :
-Erytrocyt e : hypochrom, microcyter
Promielosit 6% -Leukocyte : increased
Met5aielosit 2% -Trombocyte : increased, giant trombocyte +
Faal Haemostasis :
Prolong PTT, prolongAPTT
Lab Value Lab Value
Urinalysis 10 x
SG 1.030 Epithelia 3.3

PH 6.0 Cylinder +

Leucocyte - Hyaline -

Nitrite - Granular 8-10

Protein 2+ Leukocyte 1.6

Glucose 3+ Erythrocyte 4.2

Erythrocyte 3+ 40 x
Erythrocyte 4.2/hpf
Keton urine 3+ Leukocyte 1.6/hpf
Urobilinogen - Crystal -
Bilirubin + Bacteria 10.1x10 3
 BGA
Temp 37 C O2 10 lpm
PH 6.64 7.35-7.45
PCO2 34.6 35 45 mmHg
PO2 102.5 80 100 mmHg
HCO3 3.7 21 28 m mol/L
O2 sat Art 84.7 > 95 %
BE -33.7 (-3) - (+3) m mol/L
True o2
Conclusion :asidosis
ECG (pict)
 ECG (13/4/2012)
Sinus tachycardia, heart rate 115 bpm
Frontal Axis :N
Horizontal Axis : CCWR
PR interval : 0.12
QRS complex : 0.08
QT interval : 0. 28

Conclusion : Sinus tachycardia HR 107 bpm

RBBB incomplete
CXR (pict)
 CXR (13/4/2012)
AP position, asymmetric, too strong KV,enough Inspiration
Trachea deviated to the left
Soft tissue and bone thin
Hemidiaphragma D/S (domeshape/ domeshape), tenting
(+)
Sinus prenicocostalis angle D/S (sharp/sharp)
Pulmo : fibroinfiltrat (+)
Cor : looks rectrated to the left, site N, CTR hard to
evaluate

Conclusion:
 CUE AND CLUE PL IDx PDx PTx PMo

Male/65 yo 1. Acute 1.1 rotavirus Diet 1900 kcal/d, subj

Diarrhea watery 1.2 ETEC low fiber
Nausea diarrhea+mo 1.3 diabetic IVFD NaCl 0.9% 20
Vomiting derate gastroenterop tpm
Abdominal pain dehidration athy PO: attapulgitte 2
colicky tab/diarrhea, max
10 tab/d
Male/65 yo 2. DM type 2 Inj. intermediate act HbA1
DM 10 years insulin 0-0-10 IU SC C
RBS 510 mg/dl Inj. short act insulin FBG
Treated by insulin 4-4-4 IU SC 2HPP
uncontrolled BG

Male/65 yo 3. Chronic 3.1 Lung TB AFB Confirm diagnosis AFB

Cough 3 months Lung 3.2 chronic staining Subj
CXR fibroinfiltrat + infection bronchitis CXR
Trachea deviated to
left
Heart rectracted to
left
Tenting (+)
Treated by isoniazid
 CUE AND CLUE PL IDx PDx PTx PMo

Male/65 yo 4. Azotemia 4.1 dt Treat comorbidities Ureu

Ureum 57.9 dehidration m
Creatinin 1.59 creati
nin

Male/65 yo 5. 5.1 dt no 1 IVFD NaCl 0.9% 20 SE

Na 126 Hyponatremi tpm
Osm 280 a hypovolemi
hypoosmolar
Thank you