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dr. Dian DUTY REPORT 15 NOPEMBER 2013 dr. Dian, dr. Rini, dr. David dr. Saras, dr.

Eva dr. Andri dr. Sri Sunarti, SpPD

Mr. Abdu Rahman/62 years old/Ward 28 Anamnesis: Chief complaint: weakness History of Present Illness Patient has became weak, unable to walk, and looked very sleepy since 12 hours before admission. Previously he has been suffering from mild grade fever and cough with yellowish sputum, and decrease of appetite since 4 days ago. He didnt eat much because he felt nausea and his tongue felt bitter. His cough actually occur more than 1 month but in moderate degree. He often felt shortness of breath when he walk more than 20 meters. He also felt headache. He still consumed glibenclamide 3 times 5 mg during his decrease of appetite. He used to had this symptoms about 2 months ago and at that time, his blood glucose level was very low, and he was hospitalized. History of Past Illness He consumed glibenclamide because of having diabetes mellitus known since 2 years ago. He also has had hypertension since 5 years ago and routinely had medical check up at Outpatient Clinic of Cardiovascular Disease since 3 months ago after being hospitalized at CVCU RSSA due to cardiac problem. He got ISDN, ASA, furosemid, captopril, and simvastatin. Social History He works as. She has married and has children. He smoked cigarette drink alcoholic beverages nor traditional potion. Family History -

Physical Examination General appearance: looked moderately ill GCS: 2.3.3 at Emergency Room, and 4.5.6 after bolus of Dextrose 40% Blood pressure: 120/70 mmHg Pulse rate: 100 beats/minute regular Respiratory rate: 20 times/minutes Axillary temperature: 37,3C

Head and neck Anemic: - Icteric: - sianosis: Lymphnode enlargement: - JVP: R+0 cmH2O Chest Heart


Abdomen Extremity

: Ictus was visible and palpable at ICS V 1 cm from left MCL Right heart margin: right sternal line, left heart margin: at location of ictus cordis Heart rate: 100 beats/minutes, S1 and S2 were single, no murmur : Chest expansion left = right, stem fremitus left=right, respiratory rate: 20 times/minute Sonor in all area of left and right lungs, bronchovesicular in all area of the lungs, no rhonkhi, no wheezing : Flat, supple, normal bowel sound, liver span: 7 cm, Traubes space tympany : Warm acral, leg edema -/-

LABORATORY FINDINGS 15 NOPEMBER 2013 Laboratory Hb Leucocyte Hematocrit Thrombocyte MCV MCH MCHC Differential count SGOT SGPT RBS Ureum Creatinine Natrium Kalium Chloride Result 11,20 10.100 35,50 472.000 74,30 23,40 31,50 1,0/0,5/74,5/9,6/14,1 18 19 43 139,40 3,06 129 4,66 104 Normal Value 11,4-15,1 4.700-11.300 38-42 142.000-420.000 80-93 27-31 32-36 0-4/0-1/51-67/25-33/2-5 0-32 0-32 <200 16,6-48,5 <1,2 136-145 3,5-5,0 98-106 Unit g/dL /L % /L fL pg g/dL % U/L U/L mg/dL mg/dL mg/dL mmol/L mmol/L mmol/L

ELECTROCARDIOGRAPHY 15 NOPEMBER 2013 Sinus rhythm, HR: 120x/minute Frontal axis: left axis deviation Horizontal axis: counter clockwise rotation PR interval: 0,16 second QRS interval: 0,08 second QT interval: 0,40 second Conclusion: sinus tachycardia, with heart rate: 120x/minute, andleft axis deviation CHEST X RAY 15 NOPEMBER 2013 AP position, asymmetric, enough KV, enough inspiration

Trachea in the middle Mediastinum is normal Hemidiaphragma: right is dome shape, left is dome shape Costophrenical angle: right is sharp, left is sharp Cardiothoraxis index: 60% Cardiac waist + Fibroinfiltrate in upper until lower part of both lungs Conclusion: cardiomegaly (left ventricular hypertrophy) and lung tuberculosis

PROBLEM ORIENTED MEDICAL RECORD Cue and Clue Male/62 years old Anamnese: Weakness, sleepy, consume glibenclamid, low intake Physical examination: GCS: 2.3.3 at Emergency Room HR: 120 beats/minute Clammy acral at Emergency Room Laboratory: Random blood glucose level: 43 mg/dL Problem List Initial Diagnosis Planning Diagnosis Has been confirmed Planning Therapy Stop consuming glibenclamide Bolus Dextrose 40% 50 mL Continued with infusion of Dextrose 10% 1.500 mL/24 hours Planning Monitoring and Education Monitoring: Subjective Vital signs Random blood glucose every 6 hours

1. Hypoglicemia 1.1 Due to drug induced (glibenclamid) 1.2 Low intake

Education: Stop consume glibenclamid Free diet for 2 days Stop consume glibenclamid After blood glucose level when having decrease og reach 100-200 mg/dL, appetite change infusion into Dextrose 5% 1.500 mL/24 hours After stable at blood glucose level 100-200 mg/dL, change into NaCl 0,9% 1.500 mL/24 hours Free diet

Male/62 years old Anamnese: History of diabetes mellitus for 2 years Routinelly consume glibenclamid

2. Diabetes mellitus type 2 with azotemia

Fasting blood glucose level 2 hours post pandrial blood glucose level

Waiting for result of fasting blood glucose level and 2 hours post pandrial blood glucose level

Monitoring: Subjective Vital signs Fasting blood glucose level 2 hours post pandrial blood glucose level

Laboratory: Ureum: 139,04 mg/dL Creatinin: 3,06 mg/dL

HbA1c Lipid profile Uric acid level

Considering the administration of insulin Low calorie and low glucose diet

HbA1c Natrium, kalium, chloride, calcium, phosphat Ureum Creatinin Uric acid Lipid profile Urine production Education: Control routinely to Endocrine Department Low calorie and low glucose diet

Male/62 years old Anamnese: History of hypertension History of diabetes mellitus Laboratory: Ureum: 139,04 mg/dL Creatinin: 3,06 mg/dL BUN/creatinin: 21,22

3. Azotemia

3.1 Prerenal azotemia 3.1.1 Dehydration due to low intake 3.1.2 Due to heart failure 3.2 Renal azotemia 3.2.1 Diabetic nephropathy 3.2.2 Hypertensive nephrosclerosis

Urine analysis Fraction excretion of natrium Plasma specific gravity Urine specific gravity Abdominal ultrasonography Renal biopsy

Treat underlying disease

Monitoring: Subjective Vital signs Natrium, kalium, chloride, calcium, phosphat Ureum Creatinin Uric acid Urine production Urine analysis Education: Low salt diet

Male/62 years old

4. Heart failure 4.1 Due to stage C hypertensive heart

Echocardiography Treat underlying disease

Monitoring: Subjective

Anamnese: Shortness of breath when walking far distance, history of hypertension and diabetes mellitus, history of hospitalization in CVCU Physical examination: Ictus at 1 cm lateral midclavicular line sinistra Electrocardiography: Left axis deviation Chest X Ray: cardiomegaly (left ventricule hypertrophy) Male/62 years old Anamnese: History of hypertension and routine consume captopril Physical examination: Ictus at 1 cm lateral midclavicular line sinistra Electrocardiography: Left axis deviation Chest X Ray: cardiomegaly (left ventricule hypertrophy) Male/62 years old

functional class III


Lipid profile

Low salt and low fat diet

4.2 Due to coronary Coroner artery disease angiography 4.3 Due to diabetic cardiomyopathy 4.4 Due to uremic encephalopathy

Vital signs Electrocardiography Echocardiography Education: Low salt low fat diet

5. Hypertension on treatment

Blood pressure

Amlodipin 1x5 mg tablet Monitoring: Subjective Low salt low fat diet Vital signs Education: Low salt low fat diet

6. Chronic

6.1 Lung tuberculosis Sputum gram,

Ambroxol 3x30 mg


cough Anamnese: Shortness of breath, cough, yellowish sputum, moderate grade fever, suffered from diabetes mellitus Physical examination: Bronchovesicular sound in all area of both lung Chest X Ray: fibroinfiltrate on both lungs

far advance AFB, culture, 6.2 sensitivity test Bronchopneumonia

Antibiotics: waiting for the result of sputum analysis

Subjective Vital signs Chest X ray

Education: If lung tuberculosis: use Use mask treatment with oral antituberculosis category I (2HRZE/4H3R3) If bronchopneumonia: Ceftriaxone 2x1 gram intravenous Ciprofloxacin 2x200 mg infusion intravenous Chest physiotherapy

Male/62 years old Anamnese: Nausea and decrease of appetite

7. Dyspepsia syndrome

7.1 Diabetic gastroparesis 7.2 Gastritis 7.3 Peptic ulcer disease

Gastric emptying Metoclopramid 3x10 mg test when having vomiting and nausea Endoscopy Omeprazol 2x20 mg Abdominal tablet ultrasonography

Monitoring: Subjective Vital signs Education: Avoid acidic food