MORNING REPORT

Wednesday, June 1st2011

PHYSICIANS INCHARGE: IA : dr. Asri, dr. Yuni, dr. Lowry IB : dr. Angga, dr Retno II : dr. Didik III : dr. Niniek Budiarti, SpPD-KPTI

Summary of Data Base

Mrs Chayumi/51yo/W26 Chief Complain : leg swelling Patient suffered from left leg swelling since 2 weeks before admissio, worsening in the last 1 week, first she felt both leg was swollen but now only left leg swollen accompanied with pain at her hip, stabbng like, didnt radiated (localized).

Patient also suffered from decreased of vision since 2 yeasr and

worsening in the last 2 weeks. She also often felt cold sweating, nausea, sometimes vomiting and also epigastric pain since 2 years ago, intermittenly.

Summary of Data Base

She had already checked at general practician and had been diagnosed as Diabetes Mellitus type 2 since 7 years ago with RBS at that time was 350, she also done abdominal USG. Got therapy Furosemide, Glimepirid, Ofloxacin and Antacida.

The last she consumed it was in 2 days ago and unroutinely controlled. Defecation
was in normal limit and urination was decreased but still often micturition. She complained fever intermittenly and also cough with whitish sputum in

the last 2 months ago and got medication for it. She didnt work anymore since 2
years ago.

Physical examination
BP = 120/70 mmHg PR = 112 bpm RR = 24 tpm GCS 456 Cataract OD/OS +/+ visus hard to evaluate Tax : 36.3 C General appearance looked moderately ill Head Pale conjunctiva +

Neck
Chest Heart:

JVP R + 0 cmH2O
Ictus invisible and palpable at MCL ICS V Sinistra LHM ictus, heart waist + RHM: SL Dextra S1, S2 single with no murmur Symetric, SF D = S, s s v v s s vv s s vv Rh - --Wh - --

Lung:

Abdomen

liver span 10cm,troube space tympani, bowel sound (+) normal Catheter urine 1100cc/3hours Anemi +/+ edema at left leg A dorsalis pusation S hard to evaluate due to edema

Extremities

Lab Leukocyte Haemoglobine PCV Trombocyte

Value 24000 5.0 16.0 747000

3.500-10.000/L

Lab Natrium Kalium Chlorida RBS Albumin

Value 116 4.66 88 650 3,5-5,5 g/dL 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

MCV MCH
SGOT SGPT

78 24.5
14 16 11-41U/L 10-41U/L

eGFR osm
Ureum Creatinine

16.86 268
199.5 3.15

ml/mnt/1.73 mosm
10-50 mg/dL 0,7-1,5 mg/dL

Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin
1.015 5 + 4+ 5+

Value

Lab 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x

Value
+ -

Eritrosit
+ -

2-3 3-4 + -

Leukocyte Crystal Bacteria

BLOOD GAS ANALISIS

pH : 7.289 pCO2 : 26.7 mmHg pO2 : 110.7mmHg HCO3 : 15.0mmol/L O2 sat : 97.5% BE : -14.2m mol/L Conclussion : metabolic acidosis

ECG (//2011)
Sinus rhythm, heart rate 102 bpm Frontal Axis : normal Horizontal Axis : normal PR interval : 0.20 QRS complex : 0.04 QT interval : 0.24

Conclusion : sinus rhythm HR 102 bpm

CXR (//2011)
AP position, asymmetric, enough KV, less Inspiration Trachea in the middle Soft tissue and bone normal Hemidiaphragma D/S domeshape Sinus prenicocostalis angle D/S sharp Pulmo : infiltrate in both of the lung Cor : CTR 57%, heart waist+

Conclusion: cardiomegaly

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/51yo DM type 2 for 7 years BP 120/70mmHg PR 112tpm RR 24 tpm RBS 650 mg/dl Osm 268 mosm Keton urine + BGA : metabolic acidosis Anemia Normochrome Normocyter Hb 5.0 MCV/MCH 74/24.5

1. Hyperglycemia state

1.1 KAD 1.2 Mix with HHS

FBG/2hPP

O2 2-4 lpm NC IVFD NS 0.9% 1000cc/2hours Actrapid 10 iu iv bolus if RBS >250 Line I : Actrapid drip 5 iu/hour Line II : KCl drip 25meq in 500cc NS 10 tpm Until RBS < 250 Line I : Drip Actrapid 2.5iu/hour Line II : Drip KCl if RBS < 180 Drip until 2 hours Patient could eat Diet 1750ccal/day Inj Insulatard 0-10iu Inj Actrapid 4-4-4iu
Inj Ketorolac 1 amp if pain

FBG 2hPP RBS/h our Electro lyte serum /4 hours BGA/6 hours

Female/61yo Left leg swelling Hip pain Edema leg sinistra

2. Hip Pain

2.1 Fracture Pelvis Patologic Pelvis AP/Lateral Sinistra 2.2 Musculosceletal disorder

Pain edema

Female/51yo Left leg swelling Edema pitting leg sinistra ABI score 1 A dorsalis pedis S hard to evaluate

3. Leg swelling unilateral

3.1 Deep Vein Thrombosis

Doppler USG

Po ASA 1x80mg

Subjec tive Arteria l pulsati on Edema

Female/51yo DM type 2 7 years Ur/Cr 199.5/3.15 eGFR 16.86 ml/mnt/1.73 Abdominal USG chronic parenchymatous renal disease Female/51yo Trombocyte 747000

4. CKD stage IV

4.1 DM Nephropathy 4.2 PNC

Abdominal USG

Regulate blood glucose first Fluid balance negative 500cc/day Kidney diet 1750ccal/day

Ur/Cr Vital sign Urine produc tion

5. Trombocytosis

5.1 Trombocytosis primary 5.2 Trombocytosis secondary

Blood smear

CBC (tromb ocyte)

Female/51yo Natrium 116 Osm 268 mosm Edema + Female/51yo Decreased of vision OD/OS Cataract OD/OS Female/51yo Pale conjunctiva + Hb 5.0 g/dl MCV 78 MCH 24.5 Female/51yo Low grade fever Cough with withish sputum 2 moths Leucocyte 24000

6. Hyponatremia hypoosmolar hypervolemia 7. Blurred vision OD/OS

6.1 dilutional

FE Na

Fluid balance negative 500cc/day

Electro lyte serum

7.1 Cataract senilis 7.2 DM Retinopathy 8.1 Chronic Diasease 8.2 Low Intake

Funduscopy

Consult to Eye Department

Visus

8. Anemia Normochrome Normocyter

Blood smear, reticulocyte count

Transfussion PRC 1 kolf/day until Hb>8g/dl

CBC (Hb)

9. Chronic Lung Infection

9.1 Lung TB 9.2 Bronchitis Chronis

Sputum cultura and sensitivity test

Inj Ceftriaxone 2x1g iv

Cough T ax

Thank you