MORNING REPORT

Wednesday, July 6th 2011

PHYSICIANS INCHARGE: IA : dr. Asri, dr. Budi, dr. Lowry IB : dr. Andri, dr. Satriyo II : dr. Siti Fatma III : dr Sri Sunarti, SpPD Moderator : dr. Budi Darmawan, SpPD-KHOM

Summary of Data Base

Mr Sugeng Suyoso/59yo/W26 Chief complaint : blacktarry stool Patient suffered from blacktarry stool since 1 day before admission, change diapers until 2 times, volume about 2 glass/diarrhea. 2 weeks ago, patient admitted in RSSA Malang with chief complaint fall in bath room and couldnt woken up, diagnosed as stroke. Medical History :

1. DM since 20 years, go to PHC, got 4-5drugs, unknown,

2. Hypertension since 11 years ago, BP 160/ 3. Heart failure 12 years, post bypass operation last medication was in 1 day before admission Patient routinely consumed herbal medicine Mahkota Dewa, Sun Chorella, TianShi to relieved her diasease Petient bed ridden since 2 years ago because he usually felt fatigue and had catharact left eyes so he afraid to fall

Physical examination
BP = 70/palp (ER) 130/80 mmHg (W) PR = 105 bpm (ER) RR = 24 tpm GCS 456 Catharact S, pupil D light reflex + NGT - hematemesis Tax : 36.5 C General appearance looked severely ill Head Neck Chest Heart: Pale conjunctiva + JVP R + 2 cmH2O Ictus invisible and palpable at 2m lat MCL ICS V Sinistra LHM ictus, heart waist + RHM: SL Dextra S1, S2 single with no murmur SF D = S, s s v v s s vv s s vv Rh - --Wh - ---

Lung:

Abdomen Genetalia externa

liver span 10cm,troube space tympani, bowel sound (+) increase RT melena +, Catheter urine inserted urine production 200cc/1hour

Extremities

Anemi +/+ cold acral (ER) warm (W)

Lab Leukocyte Haemoglobine PCV Trombocyte MCV MCH SGOT SGPT

Value 14.000 9.0 25.7 217 000 84 29.2 16 12 11-41U/L 10-41U/L

3.500-10.000/L

Lab Natrium Kalium Chlorida

Value 135 4.37 103 136-145 mmol / L 3,5-5,0 mmol / L 98-106 mmol / L

11,0-16,5 g/dl 35-50% 150.000390.000/L

RBS Albumin Ureum Creatinine Ppt Aptt

404 2.75 49.0 1.28 16.3 37.9

3,5-5,5 g/dL 10-50 mg/dL 0,7-1,5 mg/dL 12.1 28.3

Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin
1.015 6 3+ 2+ 5+

Value

Lab 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x

Value
+ -

Eritrosit
2+ -

4-6 20-25 + +

Leukocyte Crystal Bacteria

ECG (6/7/2011)
Sinus rhythm, heart rate 94 bpm Frontal Axis : normal Horizontal Axis : normal PR interval : 0.14 QRS complex : 0.04 QT interval : 0.34 PVC occasional Conclusion : sinus rhythm HR 94 bpm

CXR (3/07/2011)
AP position, asymmetric, enough KV , less Inspiration Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and left hemidiaphragm are dome-shape Pulmo : looks normal Cor : CTR 63%, heart waist +, conus pulmonalis prominent, calcification of the aorta Conclusion: cardiomegaly, calcification of the aorta

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/59yo GCS 456 Cold acral BP 70/palp PR 105tpm RR24tpm Urine production 200cc/hour
Male/59yo Hematemesis Melena Post shock hypoglycemia RT Melena + Anemia N-N Hb 9.0 g/dl MCV/MCH 84/29.2

1. Shock condition

1.1 shock hypovolemic 1.1.1 due to on going bleeding

CVP

O2 8-10lpm NRBM Insert NGT Insert catheter NS 0.9% 250cc Rehydration 1000cc/hour IVFD NS 0.9% 20tpm

Vital sign Urne produ ction Acral bleedi ng

Bblee ding tende ncy Vital sign

2. 2.1 Peptic Hematemesis Ulcer Disease Melena 2.1.1 due to NSAID Gastropathy

endoscopy O2 8-10lpm NRBM IVFD NS 0.9% 20tpm Insert NGT gastric lavage/8 hours If clear start diet 6x200cc Inj Omeprazole 1x40mg iv the drip Omeprazole 8mg/hour

Male/59yo Hyperglycemic state RBS 404mg/dl

3.DM type 2 normoweight uncontrolled 4.1 HHD 4.2 ASHD

Inj Insulatard 0-10iu sc night Inj actrapid 4-4-4iu sc

FBG 2hPP HbA1C Subjec tive Vital sign

Male/59yo 4. HF stage C Hypertension st II FC II Ictus 2cm lat MCL ICS V Sinistra Chest xray : cardiomegaly, conus pulmonalis prominent, calcification of the aorta Male/59yo Leucocyte 14000 Leucocyturia 3+ 20-25/hpf Male/59yo Albumin 2.75 Proteinuria 2+ 5. Urinary tract Infection

5.1 Lower UTI 5.2 Upper UTI

Urine culture and sensitivity test Protein esbach

Inj Ciprofloxacin 2x2oomg iv

Fever Subjec tive

6. Hypoalbumine mia

6.1 Renal loss 6.2 low intake

albumi n

Thank you