Morning Report

August, 18th 2014

PHYSICIANS INCHARGE:
IA
: dr. Bayu, dr. Gerry, dr. Rere
IB
: dr. Zen, dr. Diana, dr.Herman
II
: dr. Eva
III
: dr. Didi, SpPD
MODERATOR : dr. Budi Darmawan, SpPD-KHOM

Summary of Data Base

Mr. D/ 58 yo/ W.27

Chief complaint: Itchy and redness all over the body
(Aloanamnesa and Heteroanamnesa)
Patient suffered from itchy and redness all over the body since 4 days before
admission at RSSA. He experienced this when he was hospitalized at RS Lawang for
11 days. He was admitted because of shortness of breath. He received 4-5 kind of
drugs, one of it was ciprofloxacine injection. The patient also complained about
nausea and vomiting.
Patient suffered from prostate enlargement since 1 years ago but not routinely
treated. He consumed hytrin 1 times/day but he didnt take it anymore.
Sometimes when he complained about urinaating difficulty, he used urine
catheter. Since three weeks ago he is using urine cathteter until now and it has
never been replaced.
Patien suffered from hypertension since 1 year ago but not routinely controlled.
He never complained about decrease of appetite, loss of the weight, increase of
urination or exaggerated thirst.

 When the patient was admitted at RSSA, he complained

itchyness again while being administered ciprofloxacine
injection. After that the medicine was stopped.
History social :
Smoker 20 year, 5 bars/day

Physical examination
BP = 160/100 mmHg

Tax : 36,7 C

PR = 80 regular strong RR =26 tpm,

General appearance looked moderately ill

looked overweight

GCS 456

Head

Pale conjunctiva +

Pupil isocor 3 mm/3 mm

Neck

JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest

Heart:

Ictus invisible and palpable at ICS V, 2 cm lateral from MCL Sinistra

LHM ictus,
RHM: SL D
S1, S2 single, murmur (-)

Lung:

Symetric, SF D= S

bv bv
bv bv
bv bv

Rh - ---

Wh

- ---

Abdomen and Genital

Flat, Soefl, liver span 8 cm, traube space tympani, shifting dullness (-)
bowel sound (+) normal RT : TSA normal, flat sulci medianus, mass at
superior pole, smooth surface, solid consistency, tenderness(-), blood (-)

Extremities

Oedema -/-

Skin

Generalized Erhythematous

Laboratory finding (August, 17th 2014)

Lab

Value

Lab

Value

Leukocyte

16260

3.50010.000/L

Natrium

127

136-145 mmol / L

Haemoglobine
MCV

13.7
87

11,0-16,5 g/dl
80-97

Kalium

4.58

3,5-5,0 mmol / L

MCH

28.2

26,5-33,5

Chlorida

`101

98-106 mmol / L

PCV

42.2

35-50%

Osmolarity

289.36

Trombocyte

92000

100.000390.000/L

SGOT

16

11-41U/L

SGPT

82

10-41U/L
<200

Eo/BasNeu/Ly/ 0/0/72/25/2
Mo
Ureum

143.1

10-50 mg/dL

RBS

472

Creatinine

1.5

0,7-1,5 mg/dL

PPT

10.62

BUN

44.57

APTT

29.10

URINALYSIS
Result

Result
SG

1.025

10 x

PH

6,0

Epithelia

Leucocyte

3+

Cylinder

Nitrite

Hyaline

Protein

1+

Granular

Glucose

2+

Leukocyte

Erythrocyte

2+

Erythrocyte
40 x

Keton urine

Eritrosit

109.2

Urobilinogen

Eumorfik

positif

Bilirubin

dismorfik

Leukocyte

113.9

Bacteria

41859.6 x 103 /mL

jamur

++

Laboratory Finding
BGA

Value

(Without oxygen
supplementation)

PH

7.32

7,35-7,45

PCO2

40.8

35-45

PO2

105.8

80-100

True O2

22.4

HCO3

21.1

21-28

O2 saturation

97.6%

> 95%

Base Excess

-5.2

-3 until +3

Conclusion

Acidosis Metabolic partially compensated with severe

hypoxemia

ECG

Sinus Rhtym, Heart rate 102 bpm

Frontal Axis
: Left Axis Deviation
Horizontal Axis
: normal
PR interval
: 0,08
QRS complex
: 0.04
QT interval
: 0.28
Conclusion : sinus tachycardia with HR 102 bpm

CXR August, 15th 2014

CXR August, 15th 2014

AP position, asymetric, enough inspiration

soft tissue thin, ICS: widening
Trachea in the middle
Hemidiaphragma D/S domeshape
Sinus costophrenicus D/S: flattening
Pulmo D/S: increased of BVP, thickening of hillus
Cor : site normal, shape normal, size CTR 47 %
Conclusion : Emphysematous lung

CUE AND CLUE

Male/ 58 yo/W. 27
A
Eritema all body
Itching when receiving
ciprofloxacine injection
Nausea
PE
GCS : 456
BP : 160/100 mmHg
PR : 80 bpm Regular,
strong
RR : 26 tpm
Tax : 36,7
LAB
Leuco : 16.260
Neut : 72%

PL
1. Drug
eruption

IDx
1.1 Due to
ciprofloxa
cin ?

PDx
-Skin prick
test

PTx
O2 2-4 lpm NC
IVFD NaCL 0.9% 30 DPM
Stop ciprofloxacine
injection
Inj Diphenhidramin 1
amp IV
Inj methylprednisolon
1x 62.5 mg IV
Mebhidroline
napadisilat 1 x 10 mg

PMo
S, VS, rash +
itchyness
P Edu:
Planning
diagnostic,
Prognosis, and
therapy

CUE AND CLUE

Male/ 58 yo/W. 27
A
Cateterization since 3
weeks (BPH)
PE
GCS : 456
BP : 160/100 mmHg
PR : 80 bpm Regular
RR : 26 tpm
Tax : 36,7
LAB
Leuco : 16260
Neut : 72%

PL
2. UTI

IDx
2.1 catheter
related UTI

PDx
Urine
culture,
gram
staining,
sensitivity
test

PTx
-Replace catheter
Drink enough water
- Inj ceftriaxone 2x1 gram
(skintest)

PMo
S, VS,
Urine
ouput,
UL

Ped:
Diagnosis
, Therapy

UL: (HPF)
erit : 109.2, leukocyte
113.9
Male/ 58 yo/W. 27
Lab
RBS : 472 mg/dL

3. DM Type 2
newly
diagnosed

HbA1C,
FBG
2HPPBG

Low calory diet, 1,900

Kcal/day
Inj. Intermediate insulin 00-10 IU SC

S, VS
FBG,
2HPPBG

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/ 58 yo/W. 27
LAB
RR : 26 tpm
Ur : 143.1
Cr :1.5
BUN/CR ratio : 44.57

4. Azotemia

4.1Prerenal
4.1 low intake
4.2 Increase of
IWL

-IVFD NaCl 0.9% 500cc

30 DPM
-Avoid nephrotoxic drugs
-Fluid balance

Subj.com
plain
Urine
output
Ur/CR

Male/ 58 yo/W. 27
A
Hypertension since 1
years ago
GCS : 456
BP : 160/100 mmHg
PR : 80 bpm Regular,
strong
Tax : 36,7

5. HT grade II

5.1 Secondary
5.1.1.
5.1.2.

Low sodium salt < 2

gram/day
Telmisartan 1x 80 mg

Subj.com
plain,VS

5.2 Primary

CUE AND CLUE

PL

Male/ 58 yo/W. 27
A
History of SOB
Cough
Heavy Smoker
Auscultation:
bronchovesiculer at all
area
CXR: emphysematous
lung

6.COPD (stable
condition)

Male/ 58 yo/W. 27
A
BPH was diagnosed 1
years ago
Drug hytrin but
unroutinly
Used catetherization
about 3 weeks
PE
RT : TSA normal, flat sulci
medianus, mass at
superior pole, smooth
surface, solid consistency,
tenderness(-), blood (-)

7. BPH

IDx

USG Urology

PDx

PTx

PMo

O2 2-4 lpm NC
Nebulizer beta 2 agonis (if
needed)

S,vs

Hytrine 1x1mg
Consult to urology dept

S
VS
urine
productio
nS

Hypertension

BPH

Problem analysa
Eritema all
body

3 weeks
Catetherization

BPH
UTI
Ciprofloxacin

Risk Factor Analysis

UTI
1. Women
2. Menopause
3. Pregnant
4. BPH
5. Using Foley cathether
6. Diabetes
7. Kidney problems
8. Neurogenic bladder
9. Immunocomprimised
10. Vesico ureteral reflux

Risk Factor Analysis

Diabetes melitus
1. Obesity
2. Sedentary lifestyle
3. Dislipidemia
4. Unhealthy eating habit
5. Family history and genetics
6. Increased age
7. High Blood Pressure and high cholesterol
8. History of gestasional Diabetes

Management analysis

bed rest
O2 NC 2 -4 L/minutes

Diet DM 1700 kkal/day

Fluid challenge NaCl 0.9% in 2,5 L
Inj Ceftriaxone 2x1g IV
Inj difenhidramin

Inj methylprednisolon 1x 62.5 mg

Telmisartan 1x 80 mg
Loratadin 1 x 10 mg

Condition this morning

GCS : 456
BP : 150/90 mmHg
HR : 84 bpm
RR : 24 tpm
Tax 36,7
Urine Production : 1 cc/kgbb/hour

Thank you