Dr.

Camelia-PPDS IPD

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

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.

Summary of Data Base

He 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.

Summary of Data Base

History of drinking herbal potion since 1 year ago, 1 times per month, because of he always felt generalized weakness

Physical examination
BP = 120/80 mmHg PR = 100 bpm RR = 32 tpm GCS 456 Tax : 39,1 C General appearance looked moderately ill Head Pale conjunctiva ( - ) Scleral icteric (-)

Neck
Chest Heart:

JVP R + 0 cmH2O 45 degree

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 bv bv v v

Rh ++ ++ --

Wh ++ ++ ++

Abdomen

Flat, soufle, BS(+) N, liver span 10 cm, traubes space tympani

Extremities

Oedema - ++

Lab Leukocyte

Value 2,200

(Normal)
3.500-10.000/L

Lab Natrium Kalium Chlorida RBS Albumin

Value 125 2.96 94 87 3.13

(Normal) 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L < 200 mg/dl 3,5-5,5 g/dl

Haemoglobine 11.7 PCV Trombocyte 33.10 95,000

11,0-16,5 g/dl 35-50% 150.000390.000/L 80-96 fl 26,5-33,5 pg 11-41U/L 10-41U/L

MCV MCH SGOT SGPT

71,20 25,20 110 41

Ureum Creatinine Bil tot Bil direct Bil indirect

26.7 0.69 0.43 0.18 0.25

10-50 mg/dL 0,7-1,5 mg/dL <1,10 mg/dl < 0,25 mg/dl < 0,75 mg/dl

Eo/Ba/N/Li/Mo 0/0/93.6/ 0-4/0-1/513.2/2.3 67/25-33/2-5

Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin

Value

Lab 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x

Value

Eritrosit
Leukocyte Crystal Bacteria

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

ECG (pict)

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-V3 Conclusion : Sinus tachycardia, heart rate 140 bpm, OMI anteroseptal wall

CXR (pict)

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

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 lung Lab : 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 iv skin test first Inf. Ciprofloxacin 2x400 mg iv

VS, Subje ctive

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 lung Lab : 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

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/s Wh 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 Confirm diagnosed, t test consult VCT

VS, Subje ctive

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 VS, 30 dpm Subje Attapulgit 2 tab/day ctive, prod urine

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male/48 yo/ W 25 5. decreased of Hypoalbumin appetite, low emia intake, decreased of body weight 10 kgs in 3 months Ankles edema Alb : 3.13

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 diarrhea Decreased of appetite Low intake Moderate dehydration Na : 125 Osmolalitas

6. 6.1 GI Loss Hyponatremi a Hypoovolemi a

IVFD NS 0.9 30 tpm

VS, Subje ctive

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. 8.1 dt septic Thrombocyto condition penia

Treat septic condition and uderlying disease

VS, Subje ctive, Trom bocyt e

Condition this morning

BP : 100/70 mmHg RR : 36 tpm N : 100 tpm Tax :

Thank you