MORNING REPORT

Tuesday , 5th of Desember 2017

Presented By :
Bethari Abi Safi tri, S.Ked
M. Fathir Naman Harris, S.Ked
Yulia Fitriani, S.Ked

DOCTOR INCHARGE:
Dr. Dikara WS Maulidy, Sp.PD
 PATIENT IDENTITY

 Name : Mrs. F
 Sex : Female
 Age : 54 yo
 Religion : islam
 Tribe : Banjar
 Nation : Indonesia
 Address : sungai baru no 6 RT 02 RW 01
 Date of Hostipitalization : 10th December 2017
 AUTOANAMNESIS
CHIEF COMPL AINT : EXTREMITY WEAKNESS

Patient complained about weakness of her upper and

lower right extremity since 3 days before admission. She
cannot move her right hand and right foot. Before, she felt
that both of her foot was swelling. She declined of having
trauma before these complains.
she also complained about wound in both of her sole. This
wound appear couple days after she didn’t use shoes while
walking.
she admits having diabetes melitus for 1 year and went
to doctor. She have got 4 diff erent anti diabetics and insulin
but she only use the oral medicine and seldomly using the
insulin
she never had this kind of symptomp and sign
before.
HETEROANAMNESIS
ry of past illness: unknown
History of family illness: unknown
History of drug: No drug abuse or addiction,
patient no drinks alcohol
Allergic History : No allergic history
Smoking History: No smoking history
Social History: Patient lives with her
husband and son
 PHYSICAL
EXAMINATION
BP = 160/100 Pulse rate = RR = 21 tpm Tax : 36,8 C
mmHg 98 bpm
Regular,
normal
General appearance looked GCS E4V5M6
mildly ill
Head Pale conjungtiva Acetone breath odor
(+) Icteric (-)
Visus ; 0

Neck JVP (-) lymph node enlargement (-)

Thorax: Ictus invisible, palpable at ICS V lateral MCL sin
Cor: LHM : Ictus RHM : ICS 3 PSL dextra
S1 S2 single, murmur (-)
 Symmetric, S S V V Rh - - Wh - -
Lung: S S V V - - - -
S S V V - - - -
Abdomen palpable abdomen mass , abdominal pain (-)
Bowel sound (+) shifting dullnes (-), fluid wave (-),
striac (-)
Extremities Pitting edema (-), cold acral (-), palmar and plantar
icteric (-)
Wound at plantar pedis sinitra et dextra
Abi
Wegner
Pedis
 NEUROLOGICAL EXAMINATION

 Meningeal sign (-)

 Sensoric examination Normal
 Motoric examination Upper 3/5 lower 3/5
 Physiologic refl ex Normal
 Pathologic refl ex Babinskiy (+/?)
 LABORATORY RESULT
(MAY 9 T H , DECEMBER 2017)
Test Result Range Units
HEMATOLOGY
Hemoglobin 12,6 12.00-16.00 g/dl
Leukocyte 14,7 4.00-10.5 thousand/ul
Erythroyte 3,96 4.00-5.30 Millionul
Hematocrit 35,7 37.00-47.00 Vol%
Trombocyte 279 150-450 Thousand/ul
RDW-CV 13.0 12.1-14.0 %
MCV, MCH, MCHC
MCV 90,3 75.0-96.0 fl
MCH 31,8 28.0-32.0 pg
MCHC 35,2 33.0-37.0 %

Leukocytosis,
 Test Result Range Units

Deep Count

Gran% 85.9 50.0-70.0 %

Limfocytes% 7.8 25.0-40.0 %

MID% 6.3 4.0-11.0 %

Gran# 12.70 2.50-7.00 Thousand/ul

Limfocytes# 1,1 1.25-4.0 Thousand/ul

MID# 0,9 Thousand/ul

Glucose

Random Plasma Glucose 646 <200 Mg/dl

Liver

SGOT 31 0-46 U/l

SGPT 22 0-45 U/l

Kidney

Ureum 50 10-50 Mg/dL

Creatinine 1.1 0.6-1.2 Mg/dL

Increase of gran %, lymfopenia, hyperglichaemia,
increase of granulosit count, decrease of lympocyte
Items Result Normal Value
Natrium 129.6 135-146 mmol/l
Kalium 4.7 3.4- 5.4 mmol/l
Chlorida 97.5 95-100 mmol/l

Osmolarity = 2 ( Natrium + Kalium ) + (GDS/18) + (Ureum/6.4)

= 2 ( 129,6+4.7) + (646/18) + ( 50 : 6,4 )
= 312,21 mOsm/L

Hyperosmolar hyponatremia
 Items Result Normal Value

Urinalysis
-Appearance Clear yellow Clear yellow
-Specific gravity 1.020 1.005 – 1.030
-pH 6.5 5.0-6.5
-Ketones +3 Negative
-Protein-albumin +2 Negative
-Glucose +3 Negative
-Bilirubin Negative Negative
-Blood +3 Negative
-Nitrite Negative Negative
-Urobilinogen 0.1 0.1-1.0
-Leukocyte Negative Negative
 Items Result Normal Value

Urinalysis (sedimen)
-White blood cells 1-2 0-3
-Red blood cells 0-1 0–2
-Silinder Negative Negative
-Epithel +1 +1
-Bacteria Negative Negative
-Crystals Negative Negative
-Others Negative Negative
CXR (DECEMBER, 9 T H 2017
 INTERPRETATION OF CXR

 Position AP
 Enough QV
 Enough inspiration
 No tracheal deviation
 Soft tissue and bone are normal
 Bronchovasculare pattern is increased
 No fi brosis
 Hemidiphragma dome shape
 Costophrenicus angle dextra and sinistra is sharp
 Cardiophrenicus angle dextra and sinistra is sharp
 CTR 58%
ECG (DECEMBER , 10 T H 2017)
 INTERPRETATION OF ECG

 Sinus, rhythm
 HR : 94 x/m
 Frontal axis : normal axis deviation
 Horizontal axis : counter clock wise rotation
 PR interval : 0,16 s
 QRS duration: 0,08 ms
 T wave normal
 ST elevation (-)
 There is left ventricular hypertrophy
 Conclution : Sinus rhythm, rate 94 bpm, normal axis, LVH.
HEAD CT SCAN
 There is a hipodens
lesion on ganglia basalis
sinistra
 There is a old infark on
occipital lobe sinistra
 POMR
CUE AND CLUE Problem IDx PDx PTx Pmo Ped
List
Female/ 54yo Severe After 20 Diet : low
hiponatrem NS 3% 150 ml minutes of fluid
A ia during 20 minutes 3%
Headache Ranitidine 2x50 mg Admission,
Vomitus Purosemide 1x40mg evaluate the
Nausea sodium
Weakness
irritable SE
examination
Laboratory
Natrium 107 mmol/L Subjective
hypoosmolar Vital sign

BUN : 15,88
 CUE AND PL IDx PDx PTx Pmo Ped
CLUE
Female/65 yo 2. - - Nonfarmakologist : - Subject -
A Hypertension -Diet modification - Vital sign Educational
poorly - Change lifestyle life style
-since couple
treatment
years ago, Farmakologist :
Amlodipin 10 mg, 1
sometimes the
times/day (In the
blood pressure Morning)
was high she
even went to
the doctor if
none of other
symptoms like
headache.

PE:
•TD: 160/100
 CUE AND CLUE PL IDx PDx PTx Pmo
Female/33 yo 3. Diabetes - Non pharmachologist: • Subject • Diet
A Melitus - Diet modification • Vital sign nephrisol
Patient had specially for diabetic • HbA1C
diabetes melitus - Always use sandal if • Fasting
since couple she out from house to plasma
years ago. protect the feet. glucose
• Post
Pharmachologist : prandial
-Detemir Insulin 8 UI plasma
Laboratorium on night glucose
Random plasma
glucose : 288
Thank
you