MORNING REPORT
Wednesday, June 1st2011
PHYSICIANS INCHARGE:IA : dr. Asri, dr. Yuni, dr. Lowry IB : dr. Angga, dr RetnoII : dr. DidikIII : dr. Niniek Budiarti, SpPD-KPTI
Summary of Data BaseMrs Chayumi/51yo/W26
Chief Complain : leg swelling
Patient suffered from left leg swelling since 2 weeks before
admissio, worsening in the last 1 week, first she felt both leg was swollen but
now only left leg swollen accompanied with pain at her hip, stabbng like,
didn’t radiated (localized).
Patient also suffered from decreased of vision since 2 yeasr and
worsening in the last 2 weeks. She also often felt cold sweating, nausea,
sometimes vomiting and also epigastric pain since 2 years ago, intermittenly.
Summary of Data BaseShe had already checked at general practician and had been diagnosed as
Diabetes Mellitus type 2 since 7 years ago with RBS at that time was 350, she also
done abdominal USG. Got therapy Furosemide, Glimepirid, Ofloxacin and Antacida.
The last she consumed it was in 2 days ago and unroutinely controlled. Defecation
was in normal limit and urination was decreased but still often micturition.
She complained fever intermittenly and also cough with whitish sputum
in the last 2 months ago and got medication for it. She didn’t work anymore since 2
years ago.
Physical examinationBP = 120/70 mmHg PR = 112 bpm RR = 24 tpm Tax : 36.3 °C
General appearance looked moderately ill GCS 456
Head Pale conjunctiva + Cataract OD/OS +/+ visus hard to evaluate
Neck JVP R + 0 cmH2O
Chest Heart: Ictus invisible and palpable at MCL ICS V Sinistra LHM ≈ ictus, heart waist +RHM: SL DextraS1, S2 single with no murmur
Lung: Symetric, SF D = S, s s v v Rh - - Wh - - s s v v - - - - s s v v - - -
Abdomen liver span 10cm,troube space tympani, bowel sound (+) normalCatheter urine 1100cc/3hours
Extremities Anemi +/+ edema at left legA dorsalis pusation S hard to evaluate due to edema
Lab Value Lab Value
Leukocyte 24000 3.500-10.000/µL Natrium 116 136-145 mmol / L
Haemoglobine 5.0 11,0-16,5 g/dl Kalium 4.66 3,5-5,0 mmol / L
PCV 16.0 35-50% Chlorida 88 98-106 mmol / L
Trombocyte 747000 150.000-390.000/µL
RBSAlbumin
6503,5-5,5 g/dL
MCVMCH
7824.5
eGFRosm
16.86268
ml/mnt/1.73mosm
SGOT 14 11-41U/L Ureum 199.5 10-50 mg/dL
SGPT 16 10-41U/L Creatinine 3.15 0,7-1,5 mg/dL
Lab Value Lab Value
Urinalysis 10 x
SG 1.015 Epithelia +
PH 5 Cylinder -
Leucocyte - Hyaline -
Nitrite - Granular -
Protein + Leukocyte -
Glucose 4+ Erythrocyte -
Erythrocyte 5+ 40 x
Eritrosit 2-3
Keton urine + Leukocyte 3-4
Urobilinogen - Crystal +
Bilirubin - Bacteria -
BLOOD GAS ANALISIS
pH : 7.289pCO2 : 26.7 mmHgpO2 : 110.7mmHgHCO3 : 15.0mmol/LO2 sat : 97.5%BE : -14.2m mol/LConclussion : metabolic acidosis
ECG (//2011)Sinus rhythm, heart rate 102 bpm Frontal Axis : normalHorizontal Axis : normalPR interval : 0.20”QRS complex : 0.04”QT interval : 0.24”
Conclusion : sinus rhythm HR 102 bpm
CXR (//2011)
• AP position, asymmetric, enough KV, less Inspiration• Trachea in the middle• Soft tissue and bone normal• Hemidiaphragma D/S domeshape• Sinus prenicocostalis angle D/S sharp• Pulmo : infiltrate in both of the lung• Cor : CTR 57%, heart waist+
Conclusion: cardiomegaly
CUE AND CLUE PL IDx PDx PTx PMo
Female/51yoDM type 2 for 7 yearsBP 120/70mmHgPR 112tpmRR 24 tpmRBS 650 mg/dlOsm 268 mosmKeton urine +BGA : metabolic acidosisAnemia Normochrome NormocyterHb 5.0 MCV/MCH 74/24.5
1. Hyperglycemia state
1.1 KAD1.2 Mix with HHS
FBG/2hPP O2 2-4 lpm NC IVFD NS 0.9% 1000cc/2hoursActrapid 10 iu iv bolus if RBS >250Line I : Actrapid drip 5 iu/hour Line II : KCl drip 25meq in 500cc NS 10 tpmUntil RBS < 250Line I : Drip Actrapid 2.5iu/hourLine II : Drip KCl if RBS < 180Drip until 2 hoursPatient could eatDiet 1750ccal/dayInj Insulatard 0-10iuInj Actrapid 4-4-4iu
FBG2hPPRBS/hourElectrolyte serum/4 hoursBGA/6 hours
Female/61yoLeft leg swellingHip painEdema leg sinistra
2. Hip Pain 2.1 Fracture Patologic Pelvis Sinistra2.2 Musculosceletal disorder
Pelvis AP/Lateral
Inj Ketorolac 1 amp if pain
Painedema
Female/51yoLeft leg swellingEdema pitting leg sinistraABI score 1A dorsalis pedis S hard to evaluate
3. Leg swelling unilateral
3.1 Deep Vein Thrombosis
Doppler USG
Po ASA 1x80mg SubjectiveArterial pulsationEdema
Female/51yoDM type 2 7 yearsUr/Cr 199.5/3.15eGFR 16.86 ml/mnt/1.73Abdominal USG chronic parenchymatous renal disease
4. CKD stage IV 4.1 DM Nephropathy4.2 PNC
Abdominal USG
Regulate blood glucose firstFluid balance negative 500cc/dayKidney diet 1750ccal/day
Ur/CrVital signUrine production
Female/51yoTrombocyte 747000
5. Trombocytosis
5.1 Trombocytosis primary5.2 Trombocytosis secondary
Blood smear CBC (trombocyte)
Female/51yoNatrium 116Osm 268 mosmEdema +
6. Hyponatremia hypoosmolar hypervolemia
6.1 dilutional FE Na Fluid balance negative 500cc/day
Electrolyte serum
Female/51yoDecreased of vision OD/OSCataract OD/OS
7. Blurred vision OD/OS
7.1 Cataract senilis7.2 DM Retinopathy
Funduscopy Consult to Eye Department
Visus
Female/51yoPale conjunctiva +Hb 5.0 g/dlMCV 78MCH 24.5
8. Anemia Normochrome Normocyter
8.1 Chronic Diasease8.2 Low Intake
Blood smear, reticulocyte count
Transfussion PRC 1 kolf/day until Hb>8g/dl
CBC (Hb)
Female/51yoLow grade feverCough with withish sputum 2 mothsLeucocyte 24000
9. Chronic Lung Infection
9.1 Lung TB9.2 Bronchitis Chronis
Sputum cultura and sensitivity test
Inj Ceftriaxone 2x1g iv CoughT ax
Thank you
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