MORNING REPORT

Thursday, November 5th, 2015

COASS IN CHARGE:
Ricky Randana
Dadik Ardhi Wijaya
SUPERVISOR : dr. Gatoet Ismanoe, Sp.PD

SUMMARY OF DATABASE
Mr. S / 76 yo / W.26
History Taking: Heteroanamnesis
Chief Complain: Decrease of Consciousness
History of Present Illness :
Patient came with the chief complain decrease of
consciousness since 1 month ago, it was gradually onset. He
started difficult to communicate to his family then his son said
he could not wake him up and he only lying on bed for 1
month worsening since 4 days before admission. Patient also
complained cough since one month ago with sputum but hard
to excrete, but there was no fever.
Previously, he got accident about 6 months ago when he
repaired his house, then he fell, he got closed fracture and
operation. After 3 month, he got repair for the fracture. He
complained decreased of appetite since 3 months ago he took
only small amount of food. (3-4 times, 5 spoon each time) and
decreased of body weight about 10 kg in last 6 months. He
also had wound in his back, hip, and also his right ear about 3
months ago. He cannot move his right leg for 3 months.

History of past illness :

He was hospitalization 2 times. First about 6 months ago due
to an accident and he was got an operation and the second
times about 3 months ago because of repair post fracture
operation .
Family History : none of his family had a chronic disease
Social History : Married with 4 child, and 5 grandchild.
Pensionary. His daily activity was normal before he got an
accident (6 months ago).

Physical Examination
BP: 140/70 mmHg

PR : 100 regular
strong

RR: 28 tpm

Temp.(ax): 36.80C

General Appearance : Looked severely ill

GCS : 345
Looked underweight

Head

Anemic conjunctiva (+)

Icteric sclerae
(-)

Neck

JPP R+0cm H20

Chest

Wound at right
auricular with
necrosis tissue

Heart ictus visible and palpable at ICS V, MCL S

LHM ictus RHM SL D
S1S2 single, murmur (-)
Lung Symmetric; SF D=S; S| S
S| S
S| S

V|V
Rh - - Wh - V|V
- - BV | V
+ - -

Abdomen

Flat, bowel sound normal, liver span 8 cm, Traubes space tympani

Ext.

Warm acral . Turgor , dry skin (+)

Wound at right hip, his back with excoriation and necrosis tissue,
hiperemis, kalor (+)

Photo

Photo

LABORATORY FINDINGS
Lab

Value

Lab

Value

Leucocyte

12140

400011.000/L

Na

140

136145mmol/l

Diff count

0.0/0.0/
88.3/8.4
/3.3

0-4/0-1/5167/25-33/2-5 %

4.34

3,5-5,0
mmol/l

Haemoglobi 8.20
n

11-16,5 g/dL

Cl

113

98-106 mmol/l

MCV

89.40

80-93 f

MCH

31.00

27-31pg

Ureum

139.70

16,6-48,5
mg/dL

PCV

20.2%

40-47 %

Creatinin

3.17

< 1,2 mg/dL

Thrombocy
te

86000

142-424 1
x103/L

BUN/Cr

20.59

SGOT/AST

31

11-41U/L

SGPT/ALT

11

11-41U/L

RBS

135

Albumin

2.30

PPT / INR

12.00/11.
2

3,5-5

< 200 mg/dL

URINALYSIS
Lab

Value

Lab

Value

Cloudy

Cloudy

Clear

10 x

Color

Yellow

Yellow

Epitel

4,5 - 8,0

Cilinder

Negative

Lpf

1,010 1,015

Hialin

Negative

Negative

Negative

pH

5.5

BJ

1030

23.3

1lpf

Glucose

Negative

Negative

Granular

Protein

+1

Negative

40 x

Keton

Negative

Negative

Erythrocyte

Bilirubin

Negative

Negative

Dysmorfic

Negative

Hpf

Urobilinogen

Negative

Negative

Eumorfic

Negative

Hpf

Nitrit

Negative

Negative

Leucocyte

Leucocyte

+3

Negative

Fungi

Blood

+2

Negative

Bacteria

2,7 hpf

283.8
1582.3

3 hpf

5 hpf
Hpf
23 x
103/mL

ECG

ECG
Sinus tachycardia with HR 100 bpm
Frontal axis
: Normal
Horizontal axis
: normal
PR interval
: 0,20 second
QRS kompleks : 0,08 second
QT interval
: 0,32 second
Conclusion
: Sinus tachycardia with HR
100 bpm

CXR

Chest X-Ray
AP position, asymmetric, KV enough, enough
inspiration
Soft tissue skin, bone : normal
Trachea in the middle
Hemidiaphragm D /S dome shape
Phrenico cotalis angle Dextra & sinistra are sharp
Pulmo D/S : infiltrate
Cor site: N, Size: CTR 46 %
Conclusion : Susp. Pneumonia

CUE AND CLUE

Male/ 76 YO/
Ward 26
DOC
Prolonged
bedridden
Cough
Multiple ulcus
decubitus
Low intake
Geriatric problem
Phy. Exam
GCS: 345
BP: 140/70mmHg
PR: 100 bpm
RR: 28 tpm
T.ax: 36.8 C
Lab
Hb 8.20
Leuco 12.140
Ur/Cr:
139.70/3.17
UL
Leucocyte :
283.5

PL
1. DOC

Idx
PDx
1.1 Septic

encephalopat
hy
1.2 Uremic
encephalopat
hy

PTx
02 8 - 10 lpm via
NRBM
Inj. ceftriaxone 2x1
g
Inf. Levofloxacin 1
x500mg 1x250
mg Intravena
Rehydration
2000cc in 2 hours
maintenance 20
tpm

Pmo
VS
Subjecti
ve
Urine
output

Male/ 76 YO /
2. Septic
W.26
condition
DOC, low intake ,
multiple ulcus
decubitus due to
prolonged
bedridden
Phy. Exam
BP:
140/70mmHg
RR: 28 tpm
PR: 100 bpm
T.ax: 36.8
-Rhonki in basal
dextra lung (+)
-Multiple ulcus in
hip dextra,
auricular dextra
with necrotic
tissue (+)
LAB
Leuko : 12140
Trombo 86000
UL: Leuco 238.5

2.1 Ulcus
decubitus
gr II due to
prolonged
bed ridden
2.2
Pneumonia
2.2.1 CAP
2.2.2
Orhtostatic
2.3 UTI

Culture
sputum
, pus,
and
antibioti
c
sensitivi
ty test

Bedrest with
proper position
and
antidecubitus
bed
Equal fluid
balance
Inj ceftriaxone
2x1 gram
Inf. Levofloxcacin
1 x500mg
1x250 mg
Intravena
Wound toilet

VS
Subj
Septic
shock sign

Male/ 76 YO / 3. Anemia
w26
NN
DOC, prolonged
bedridden,
wound at
auricular and
right hip, ulcus
decubitus
Phy. Exam:
Anemic
conjunctiva (+)
LAB
Hb: 8.20
MCV: 89.00
MCH: 31.00

3.1 Chronic
disease
3.2 Occult
blood loss

Treat underlying
disease

Subj, vital
sign,
Recheck
cbc

Male/76
yo/W26
Ax:
DOC
Prolonged
bedridden,
Low intake
Phy. Exam
GCS 345
BP 140/70
mmHg
PR 100 bpm
RR 28 tpm
Lab:
WBC: 12140
PLT: 86.000
Ureum: 139.7
Creatinin: 3.17

4.
Azotemia

4.1 pre
renal
4.1.1
Septic
condition
4.1.2
Volume
depletion
4.2 Renal

Equal fluid
balance
Liquid diet
6x200cc (1cc ~
2 calories)
Loading fluid at
ER NS 2L in 2
hours
continued NS 20tpm

VS
Subjective
Recheck
ureum
creatinin
Urine
production

Male/76 yo/
W26
DOC
Prolonged
bedridden due to
post fracture
Low intake
Multiple ulcus
decubitus
Contracture due
to immobilitation
chronic
PE :
BP 140/70mmHg
PR 100 bpm
Rhonki in basal
dextra
Ulcus decubitus
with necrotic
tissue
LAB
Albumin : 2.30
g/dL
Leucocyte 12140
mg/dL
GDS 135

5.
Geriatri
c
proble
m

5.1
Prolonged
bed ridden

Proper positioning
every 2 hours with
antidecubitus bed

5.2
Immobilizati
on

Medical rehabilitation

5.3
Constipation
5.4
Malnutrition

Inserted NGT
diet: need 2100
kcal/day 6 x 200cc
+ extract protein
IVFD NS 1000cc / day

Subj
VS
Urine
output