Morning Report,

Friday, April 30, 2014

Physician In Charge:
IA : dr. Jaja, dr.Meli, dr.Ami, dr Intan
II : HCU : dr. Awan
CVCU : dr. Vina
Chief : dr. Eva
Consultan : dr. Sri Sunarti, SpPD-KGer

Summary Of Database:
Male/ 49 Yo/ W 26

Chief complaint: diarrhea

Patient had been suffering diarrhea since 5 days ago with a frequency of 4-5 times a day,
about 1/2 glass every diarrhea. At the first time diarrhea was brownish but in 2 days lattes the
color was change be redness. Passing stool was accompanied with abdominal pain especially
at left area.

He also complain nausea and vomiting since 3 days ago, contain fluid and residual foot.
Because of that he decrease of appetite, he only ate half portion rice.

He felt shortness of breath when he walk to far about 20-30 meters, sometimes used 1-2
pillows when he slept, he never woke up at night because shortness of breath and he was
diagnosed heart failure since 3 years ago and routine control to RST and got digoxin, aspilet,
furosemide, bisoprolol, spironolacton, candesartan, daneuron.

He was diagnosed hypertension since 3 years ago, routine control to RST

He is a driver married and has 2 children

Physical Examination
BP=80/50 mmHg ( drip NE) PR= 64 bpm RR = 20 tpm Ax. Temp.= 36.2 0C

General App.: looked moderately ill GCS : 456

Head Anemic conjunctiva (-) Icteric sclerae (-)

0
Neck JVP : R + 0 cm H2O; 30
Thorax Cor Ictus visible, palpable at ICS VI, 2 cm lateral MCL Sinistra
RHM ≈ PS line LHM ≈ ictus
S1S2 normal, Murmur (-), thrill (+)

Pulmo Symmetric; V|V Rh -|- Wh -| -

V|V - |- -| -
V|V -|- -| -

Abdomen Flat, BS Increase, liver span 10 cm, traube space dullness,shifting dullness (+)

Extremities Cold acral , Edema -/-

-/-

Urine production 100 cc/12 hours

Daldiono Score 5

Laboratory finding
LAB RESULT NORMAL VALUE LAB RESULT NORMAL
VALUE
Leukocyte 18910 3,500-10,000/µL Sodium 129 136-145
mmol/l
Hemoglobine 11.5 11.0-16.5 g/dl Potassium 5.1 3.5-5.0
mmol/L
MCV 75.70 80-97 µm3 Chloride 101 98-106
MCH 25.00 26.5-33.5 µm3 mmol/L
PCV 34.8 35-50% RBS 109 >200 mg/dL
Thrombocyte 244000 150,000- Ureum 148.1 10-50 mg/dL
390,000/µl
SGOT 23 11-41U/L Creatinine 2 0.7-1.5
mg/dL
SGPT 15 10-41U/L Albumin 1.71 3.5-5.5 gr/dL
Diff count 0.5/0.1/88.5/7.8/3.1 0-4/0-1/51-67/ Globulin 1.95 2.5-3.5 gr/dL
Eos/Ba/Neu/Ly/Mo 25-33/2-5
Bil T/D/I 1.06/0.92/0.14 Ca 6.9 7.6-11 mg/dL
Ca Corected
8.73
Bun/ cr 34.5 phosfor 5.4 2.7-4.5
Lymphocyte count 1475
  CXR
AP position, asymmetric, and enough KV
Soft tissue and bone are normal
Trachea in the middle
Phrenico-costalis angle dextra and sinistra are sharp
Hemidiaphragm dextra and sinistra are domeshape
Lung: bronchovascular pattern normal
Cor: shape: normal, site: normal, and size CTR: 70 %
Conclusion: Cardiomegaly

 ECG

Sinus bradicardia , HR : 50 bpm

PR interval : 0,20
QRS complex : 0,0.4
QT interval : 0,40
Frontal Axis :N
Horisontal Axis :N

Conclusion: sinus bradicardia

Cue & clue PL IDx PDx PTx PMo

Male /49 yo/ W 1.Syock 1.1.Acute Stool IVFD NS 0.9 % Subjective
26 Septic inflammatory analysis, 1500 cc in a BP
Ax : diarrhea Cultus feces hours continue HR
Diarrhea 1.1.1 and 20 dpm iv RR
Nausea Dysentri sensitivities Drip Ne 0,05-2 T ax
vomiting basiler. mcq/ Kg BB/Myn Urine
Abdominal 1.1.2 Diet 1700 production
tenderness (+) Dysentri Kcal/day low Dehydrati
Redness passing amoeba fiber, Low salt < on sign
stool 1.1.3 EHEC 2 gr/day, extra
Pe : 1.1.4 EIEC protein
GCS 456 1.4.Shigellosi Infus
BP: 80/40 mmHg Ciprofloxacine
( drip NE) 2x200 mg IV
N: 64 dpm Infus
Daldiono score : metronidazole
5 3x 500 mg,
Lab : 1x30 mg
WBC: 18910 Metoclopramide
Neutrofil : 88.5 3x10 mg IV prn
vomit
Drip NE 0.05 -2
mcq /kgBB/day
until MAP > 70,
Omeprazole
2x20 mg
Male /49/ yo 2 Heart 2.1 HHD Echocardiog Diet low salt < 2 Subjective
Ax: Failure Sc 2.2 CAD garr gr/ day Vital sign
Dipsneu de effort C fc II
Diagnosed heart
failure since 5
months ago
Consume drug of
heart
Pe :
Ictus visible
palpable at ICS
VI 2 cm lat MCL
Sinistra
CXR :
Cardiomegaly

Male /49/ yo 3. 3.1 Hepatitis HBsAg, Anti Treat underlying Subjective

Bil T/D/I : hiperbiliru viral infection HCV, USG disease BP
1.06/0.92/0.14mg bunemia 3.2 abdomen HR
/dL obstruction RR
SGOT : 23 U/L T ax
SGPT : 15 U/L
Male /49/ yo 4. 4.1 GI loss Transfusion Albumin
Ax: Hypoalbu 4.2 albumin 20% level
Diarrhea since 5 min Hypercatabol until Albumin >
days ago ic state 2.5 g/dL
Lab :
Albumin : 1.71
gr/dL

Male /49/ yo 5. 5.1 septic Treat underlying S, VS,

Ax: Azotemia condition disease Ur/Cr,
Diarrhea since 5 pre Renal 5.2 Urine
days ago Dehydration output
Pe :
BP : 80/40 mmHg
( drip NE)
N: 64
Lab :
Ur : 148.1
Cr : 2
Bun/Cr : 34.5

Male /49/ yo 6. 6.1 USG Diet low salt < 2 S, VS

Ax : Hipertensi secondary abdomen gr/ day
Diagnosed on on HT
hypertension Treatment 6.2
since 5 months Primary HT
ago
Consume anti
hypertension