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