MORNING CASE REPORT

8 JUNI 2010

IDENTITY
Initially : NNS (F)
Age
: 70 y.o
Religion : Hindu
Education: SD
Merital : Marriage (widow)
T.C
:

ANAMNESIS
Cc : Weakness
Patient (Px) complained weakness since 1 week
BATH. It was worsen 2 days BATH. The
weakness was like already had done hard work.
Px also felt (mual) but not to vomit. Cough and
flu was denied.
Px saldom felt breathlessness. There was fever,
Pain and tingling (kesemutan) on her feet.
Defecation and Urination was done as usual

Past History
Diabetes Mellitus (+) since 10 years ago.
Controlled by oral medication.
Px always controls his DM once per two
weeks to doctor
Px takes 2 kind of oral DM drugs. First
drug is eaten in the morning before
breakfast. Second is eaten in the noon
before dinner.

Family History
Diabetes Melitus (+)

Sosial Habit
Stay in the house with ..
No hard daily activity

Physical Examination

General Inspection : Moderately ill

Consiousness
: Alert
GCS
E4V5M6
BP
140/90mmHg
RR
/mnt
Pulse
80 beats/mnt
Axillary Temp.
37,5 C

 General Status
Eye : pale -/-, ikt -/-, pupillary reflexes +/+, oedema palpebra -/ ENT : within normal limit, gland swelling (-)
Neck : JVP 0 cmH2O
Thorax : symmetrical
Cor : I
: IC unseen
Pal
: IC unpalpable
Per : UB : ICS II
RB : 1 cm lateral to right PSL
LB : 1 cm lateral to left MCL
Aus : S1S2 Single Regular, Murmur(-)
Lung: I : Symmetrical
Pal
: VF N/N
Per : sonor /sonor
Aus : bronchoVes +/+, Rh -/-, Wh -/ Abdomen : I
: Dist (-)
Aus
: Normal Bowel Sound
Pal
: L: Non-palpable
S: Non- palpable
Per
: Tympany(+), shifting
Extremeties : Warm++/+ + Edema

dullness(-)
- -/- -

Laboratory Exam.
CBC
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
RDW SD
PLT
MPV

: 7,5
: 4,17
: 12,8
: 36,9
: 88,4
: 30,6
: 34,6
: 13,3
: 38,5
:101
: 7,4

Chemistry Panel
SGOT : 112,30 U/L
()
SGPT : 123,00 U/L
()
BUN : 21,80 mg/dL
()
SC
: 0,732 mg/dL
GDS : 345,80
mg/dL ()
Na
: 128,10
mmol/L
()
K
: 4,35 mmol/L

Urinalisis
PH
:5
Leu
: nitrite : prot
: 75
Gluko : 1000
Keton : Urobilinogen : norm
Bilirubin
: neg
Erytrocite : 25,00
Spec Gravt: 1,015
Clarity
: Colour : yellow
Urine Sedimentation
Lekosit 0-1 /lp
Eritrosit 0-1/lp
Epitel Cell 1-2/lp
Bakteria +/lp

 Sinus Rhytm
80x/mnt
Axis Normal

Cor
Pulmo

: CTR 54%, tail (-)

: no abnormality

Conclusion normal

Assesment
DM type II
Gastropaty DM
Hyposodium normoosmolar euvolemic
Observasi Tranaminitis e.c Susp. Fatty Liver dd/

Therapy
NaCl 0,9% 20tts/mnt
Drip Actrapid 4 U/hours if BS 250
2U/hours if BS 130 140 1U/hour
adjusted dose
Domperidon p.o 3x1
Epatin 3x1

Monitor
Vital Sign; Complaints
BS @ hour; Electrolit (Na, K) @ day

Planning
Basal Glucose, 2 hour PP; A1C, Lipid
Profile, USG Abdoment