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7/28/2019 Tn. Ngadiran, r25
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MORNING REPORT
Wednesday, July 4th 2012
PHYSICIANS INCHARGE:
IA : dr. Camelia, dr. Yasmita, dr. Galuh
IB : dr. Asri, dr. Merici
II : dr. Satriyo
III : dr. Didi Candradi K, SpPD
MODERATOR: dr. Atma Gunawan, SpPD-KGH
Dr. Camelia-PPDS IPD
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Summary of Data Base
Mr. Ngadiran / 29 y.o /w. 28
Chief Complain : generalized weakness
Patient suffered from generalized weakness since 1 month ago, he could not
do his job as meatball seller, he spent all the day in bed. In last 2 days he
could not do daily activity, he just laid on bed.
He got diarrhea since 1 month ago, 2-3 times per day, glass, yellowish
color, watery, getting worse since 2 days ago, 5 times per day, the volume
was about glass.
Nausea since this morning, no vomiting.
He got fever since last 2 days, high grade fever, sudden onset.
He got cough since more than 3 months ago, difficult to expectorate, whittish
sputum. The cough was getting worse in last a week.
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Summary of Data BaseHe always sweating in the night since 1 month ago.
He felt decreased of appetite since 1 month ago, just ate small amount of
food. His body weight was decreased about 10 kgs in 3 months.
He and his wife said that his urine sometimes accompanied with blood,
sometimes fresh blood sometimes black.
Patient went to doctor 3 weeks ago, and the doctor said that he got liver
disease. But the doctor said that he was cured 1 week after that, he was
gave some medicine, but he did not know the name of the drug.
History of smoking > 20 years, 12 bars/day
History of drinking alcohol for years, 1-2 times per month, had stopped 10
years ago.
History of drugs abuse.
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Summary of Data Base
History of drinking herbal potion since 1 year
ago, 1 times per month, because of he always
felt generalized weakness
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Physical examinationBP = 120/80 mmHg PR = 100 bpm RR = 32 tpm Tax : 39,1 C
General appearance looked moderately ill GCS 456
Head Pale conjunctiva ( - ) Scleral icteric (-)
Neck JVP R + 0 cmH2O 45 degree
Chest Heart: Ictus invisible and palpable at MCL ICS V Sinistra
LHM ictus, RHM SL, heart waist ( + )
S1, S2 single, murmur ( - )
Lung: Symetric, SF D = S bv bv Rh Wh
bv bv + + + +
v v + + + +
- - + +
Abdomen Flat, soufle, BS(+) N, liver span 10 cm, traubes space tympani
Extremities Oedema - -
+ +
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Lab Value (Normal) Lab Value (Normal)
Leukocyte 2,200 3.500-10.000/L Natrium 125 136-145 mmol/L
Haemoglobine 11.7 11,0-16,5 g/dl Kalium 2.96 3,5-5,0 mmol/L
PCV 33.10 35-50% Chlorida 94 98-106 mmol/L
Trombocyte 95,000 150.000-390.000/L
RBS
Albumin
87
3.13
< 200 mg/dl
3,5-5,5 g/dl
MCV
MCH
71,20
25,20
80-96 fl26,5-33,5 pg
SGOT 110 11-41U/L Ureum 26.7 10-50 mg/dL
SGPT 41 10-41U/L Creatinine 0.69 0,7-1,5 mg/dL
Eo/Ba/N/Li/Mo 0/0/93.6/
3.2/2.3
0-4/0-1/51-67/25-33/2-5
Bil tot 0.43
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Lab Value Lab Value
Urinalysis 10 x
SG Epithelia
PH Cylinder
Leucocyte Hyaline
NitriteGranular
Protein Leukocyte
Glucose Erythrocyte
Erythrocyte 40 x
EritrositKeton urine Leukocyte
Urobilinogen Crystal
Bilirubin Bacteria
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BGA (O2 2-4 lpm NC)
Ph : 7.72
PCO2 : 20.1
PO2 : 176.8 true O2 128% Hyperoxemia HCO3 : 26.2
BE : 6.4
Sat O2 :99,5%Conclusion : alkalosis respiratorik partially
compensated with metabolic respiratorik
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ECG (pict)
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ECG (3/7/2012)
Sinus tachycardia, heart rate 140 bpm
Frontal Axis : normal
Horizontal Axis : clock wise rotation
PR interval : 0. 14 QRS complex : 0. 06
QT interval : 0. 24
Qs pattern V1-V3Conclusion : Sinus tachycardia, heart rate 140bpm, OMI anteroseptal wall
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CXR (pict)
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CXR (3/7/201)
AP position, symmetric, enough KV, less Inspiration
Trachea in the middle
Soft tissue and bone normal
Hemidiaphragma D/S domeshape Sinus prenicocostalis angle D/S sharp
Pulmo : fibroinfiltrat all area of lung, infiltrat in aper lung
d/s
Cor : CTR 50 %, heart waist (+)
Conclusion: Lung TB milier, pneumonia CAP
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
Generalized
weakness, high
grade fever,
suddenly onset,
Chronic cough,
whittish sputum
PE :
looks moderately ill
GCS 456,
BP : 120/80 mmHg,
PR : 100 tpm, reg
RR : 32 tpm reguler
Rh at upper and
medial lung d/s
Wh all area of lungLab : Leucocyte
2.200, neutrofil
93,6%
CXR : TB Milier,
Pneumonia
1. Septic
Condition
1.1 Lung
Infection
Blood
culture and
sensitivity
test
O2 2-4 lpm NC
Soft Diet 1700
kcal/day
IVFD NS 0.9% 30
dpm
Inj. Ceftriaxon 2x1
gr ivskin test first
Inf. Ciprofloxacin
2x400 mg iv
VS,
Subje
ctive
CUE AND CLUE PL ID PD PT PM
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
Generalized
weakness, high
grade fever,
suddenly onset,
Chronic cough,
whittish sputum
PE :
looks moderately ill
GCS 456,
BP : 120/80 mmHg,
PR : 100 tpm, reg
RR : 32 tpm reguler
Rh at upper and
medial lung d/s
Wh all area of lungLab : Leucocyte
2.200, neutrofil
93,6%
CXR : TB Milier,
Pneumonia
PORT Score 138
2. Lung
Infection
2.1 Acute
Lung Infection
2.1.1 CAP
2.1.2. Lung Tb
2er infection
2.2 Chronic
Lung Infection
2.2.1 TB
Milier
Sputum
culture and
sensitivity
test, AFB
O2 2-4 lpm NC
Soft Diet 1700
kcal/day
IVFD NS 0.9% 30
dpm
Inj. Ceftriaxon 2x1
gr (iv)
Inf. Ciprofloxacin
2x400 mg (iv)
VS,
Subje
ctive
CUE AND CLUE PL ID PD PT PM
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
Generalized
weakness, high
grade fever,
suddenly onset,
Chronic cough,
whittish sputum,
oral candidiasis
PE :
looks moderately ill
GCS 456, BP :
120/80 mmHg, PR :
100 tpm, reguler,
RR : 32 tpm reguler
Rh at upper and
medial lung d/sWh all area of lung
Lab : Leucocyte
2.200, neutrofil
93,6%
CXR : TB Milier,
Pneumonia
3.
Immunocom
promised
state
3.1 dt TB
Milier
3.2 HIV stg IV
Determinan
t test
Confirm diagnosed,
consult VCT
VS,
Subje
ctive
CUE AND CLUE PL ID PD PT PM
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
Chronic diarrhea
Yellowisy watery
Fever
Decrased of urine
production
PE : px apatis
BP : 120/80 mmHg,
PR : 140 (ER), 100
(W) tpm, reguler,
RR : 32 tpm reguler
Daldiyono score : 5
4. Chronic
Diarrhea +
moderate
dehydration
4.1 HIV
4.2 colitis TB
FL, feces
culture and
sensitivity
IVFD RL 1500 cc
30 dpm
Attapulgit 2 tab/day
VS,
Subje
ctive,
prod
urine
CUE AND CLUE PL ID PD PT PM
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
decreased of
appetite, low
intake, decreased of
body weight 10 kgs
in 3 months
Ankles edema
Alb : 3.13
5.
Hypoalbumin
emia
5.1 GI Loss
5.2 Low
Intake
5.3
Hypercataboli
c state
Soft diet HCHP
ekstra white egg
Treat underlying
disease
VS,
Subje
ctive
Male/48 yo/ W 25
Chronic diarrheaDecreased of
appetite
Low intake
Moderate
dehydration
Na : 125Osmolalitas
6.
Hyponatremia
Hypoovolemi
a
6.1 GI Loss IVFD NS 0.9 30 tpm VS,
Subjective
CUE AND CLUE PL IDx PDx PTx PMo
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CUE AND CLUE PL IDx PDx PTx PMo
Male/48 yo/ W 25
Chronic diarrhea
Decreased of
appetite
Low intake
K : 2.96
7.
Hypokalemia
5.1 GI Loss
5.2 Low
Intake
5.3
Hypercataboli
c state
KSR 1 x 1 tablet VS,
Subje
ctive,
K
Seru
m
Male/48 yo/ W 25
Fever,Lung Infection
PE : ptechie (+)
Lab : Trombocyte :
95,000, Leucocyte
2.200, neutrofil
93,6%CXR : TB Milier,
Pneumonia
8.
Thrombocytopenia
8.1 dt septic
condition
Treat septic
condition anduderlying disease
VS,
Subjective,
Trom
bocyt
e
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Condition this morning
BP : 100/70 mmHg
RR : 36 tpm
N : 100 tpm Tax :
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Thank you
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