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Morning Report

Sunday, 13th October 2013


Physician In Charge: IA : dr. Anton, dr. Hesti , dr David (kardio) IB : dr. Zoraida, dr. Daru II : dr. Nicholas III : dr. Bogi Pratomo, Sp.PD-KGEH

Summary Of Database: Female/71 yo /W 26/Askes


History of present Illness

Chief complain: decreased of conciousness


She suffered from decreased of consciousness since 1 day before admission, gradually onset, the first sign was vomiting-restless-slurs speech and then deep sleep. The vomiting was transparent brown, about 3-4 glass each, without blood. After that She become restless, slurs speech and then sleep which cannot be awakening. Their family called for doctor and Then doctor said She should be brought to RSSA immediately. Previously patient had been hospitalized at Pavillion RSSA for 14 days, she had cared by four specialist: cardiologist, neurologist, internist and also medical Rehabilitation. She had been discharge 2 days ago.

History of past illness: He suffered from colon tumor and had been tumor resection 10th years ago. She was admitted in RSSA this March 2013 because of Shortness of breath and leg swelling. She had Hypertension known since march 2013. History of diabetes and allergic unremarkable.

Family history: Her mother and sister was diabetes . She is a pensioners. She had 4 children, one of her son was die because of motor accident. Reviem of systems Unremarkable

Physical Examination BP= 90/palpation mmHg PR= 90 bpm irregular RR =10 tpm on NRBM 12 Lpm saturation 95% GCS : 1 1 1 Icteric sclerae (-) Pupil isokor D/S 2 mm Neck stiffness (-) Ax. Temp.= 36.3 0C

General App.: looked severely ill Head Neck Thorax Anemic conjunctiva (-)

JVP : R + 0 cm H2O; 300, Cor Ictus invisible, palpable at ICS VI, MCL S RHM SL D LHM ictus S1, S2 single, murmur Pulmo Symmetric; SF D=S; S| S V | V Rh +|+ Wh - | S| S V | V +|+ -| S| S V |V +|+ -|soefl, BS (decreased), Liver span 8 cm, traubes space dull , Oedem-, cold acral, --

Abdomen Extremities Urine production

LABORATORY FINDINGS LAB RESULT Leukocyte 18.890 Hemoglobine MCV MCH PCV Thrombocyte 14,4 77,7 26,6 42,10 367.000

NORMAL VALUE 3,500-10,000/L 11.0-16.5 g/dl 80-97 m3 26.5-33.5 m3 35-50% 150,000390,000/l

LAB Sodium Potassium Chloride Troponin I CK-NAC

RESULT 141 5,34 109

NORMAL VALUE 136-145 mmol/l 3.5-5.0 mmol/L 98-106 mmol/L <1 mg/dL

SGOT SGPT Albumin neutrofil RBS

50 18 2,88 75.7% 111

11-41U/L 10-41U/L 3.5-5.5

CKMB PPT APTT INR 10,4 27,8 0,93 174,4

mg/dL
11,0 s 26,2 s

<200 mg/dl

Ureum

16,6 48,5

3 lactate 2,8 3,4 0,6-2,2 mmol/L creatinin 5,44


<1,2

Blood gas Analysis Lab pH PCO2 PO2 HCO3 Sat O2 BE Conclusion

Result 7,32 7,45 33,1 30,6 196,7117,4 17,2 21,2 99,6 98,8 % - 9,0 -3,1

Normal Value 7,35 7,45 35 45 mmHg 80 100 mmHg 21 28 mmol/L (-3) (+3) mmol/L

Metabolic acidosis partially compensated respiratory alkalosis

Urinalysis (waiting for results)


SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin 10 x Epithelia

Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x Erythrocyte Leukocyte Crystal Bacteria

Echocardiography: Consentric LVH with decreased in RV systolic accompanied with mild AR and mild PH Septal hypokinetic at middle and basal also middle anterior Conclusion : HHD and ischemic heart disease

CXR : AP position, asymmetric, enough inspiration, KV enough, trachea in the middle with ETT inserted, bone normal and soft tissue normal , Phrenicocostalis angle D and S Sharp, Hemidiaphragm D/S domeshaped, Pulmo: BVP normal, cephalisasi (-), infiltrate (+) Cor: aortic elongation, cardiac waist -, CTR 62%

Conclusion : cardiomegaly

ECG at RSSA: Irregularly irregular rhytm, HR 50 150 bpm, mean HR 100 bpm No P wave QRS : 0,08 s QT interval : 0,28 s FA : cannot be evaluate HA : normal Q wave at V1-V2, Strain pattern at II, AVF, V4, V5, V6 Conclusion : atrial Fibrillation NVR + OMI anterior + LVH
Problem list Female, 71yo 1. 1. Shock Decrease of condition conciousness 2. GCS 111 BP 90/mmHg HR: 90bpm Cold acral Anuria Clue and cue Planning Therapy Monitoring O2 jacksen rees 12 S Lpm VS every 15 Urine Liquid Diet 1500 production Kcal/day--NGT SE every 4 hr BGA every 6 NE 0,05-2 hr mcg/KgBW/Minutes Dobutamin 520mcg/kgbw/min Ranitidine 2x50 mg IV Treat underlying disease Consult to neurologist

Initial Dx 1.1 Septic condition 1.2 cardiogenic

Diagnosis Serial ECG Cardiac marker/6 hr

edukasi Explained recent condition, probable causes of disease,

Female 71 yo Decrease of conciousness GCS 111 History of CVA few month ago Head Ctscan ICH Ureum 174 Creatinin 5.4 Female 71 yo Decrease of conciousness GCS 111 RR 10tpm 12lpm with jacksen reese Ureum 174 Creatinin 5.4 Leucocyte

2. decreased of conciousnes s

2.1 Dt No 1 2.2 CVA 2.3 Uremic encephalopat hy

GCS

Explained recent condition, probable causes of disease,

3. Septic conditio n

3.1 Pneumonia 3.2 UTI

Blood culture and sensitivity

Inj Ciprofloxacin 2x400 mg IV Inj. Ceftriaxon 2x1 g IV

S, VS

Explained recent condition, probable causes of disease,

5 18.890 CXR: pneumonia Female 71 yo Ureum 174 Creatinin 5.4 BUN/Cr: 14.9 CG-GFR: 7.5ml/min Female 71 yo BP 90/ECG: AF NVR+OMI

4. Azotem ia renal

4.1 Dt No 1 4.2 CKD

USG abdomen if possible

Treat underlying disease

Vs,

Explained recent condition, probable causes of disease,

5. HF st C FC IV

5.1 CAD 5.2 HHD

NT proBNP

NE 0,05-2 mcg/KgBW/Minutes Dobutamin 520mcg/kgbw/min As treat above

S, VS ECG

anterior + LVH Echocardiog raphy HHD and ischemic heart disease


Female 71 yo Suffered Albumin: 2,88 Female 71 yo Shock condition ECG atrial 6. Hypoal bumine mia 6.1 Low intake 6.2 Hypercatabol ik state 6.3 Renal loss 7.1 Dt. No 1 7.2 OMI anterior 7.3 HF st C fc4 -

Explained recent condition, probable causes of disease,

Treat underlying disease

albumin

7. AF NVR

Treat underlying disease

S, VS ECG monitoring

Fibrillation NVR + OMI anterior + LVH

Explained recent condition, probable causes of disease, Explained recent condition, probable causes of disease