MORNING REPORT

th
October 7 , 2014
Coass in charge:
Putu Nina Belinda Saka
David Chandra

MODERATOR : dr. Nur Samsu, Sp.PD

Mrs. S/61yo/W22
1. General weakness
1. 1 Nausea and vomiting
1.2 Low intake
2. Chronic lung infection
2.1 Tb paru
2.2 Brokiektasis
3. Pneumonia hcap
4. Hipokalemia
4.1 Low intake
4.2 GI loss
5. Azotemia pre renal
5.1 Volume depletion
6. Trombositopenia
6.1 Primer
6.2 Sekunder
7. Ulkus decubitus

 Mrs. S/61yo/W22
Chief complain: general weakness
Patient felt general weakness continously since 1 week ago. General
weakness would be increased if she do any activity and relieved if she
lied down on bed. She felt fatigue in all of the body, and cekot-cekot
in her feet. She would feel dyspneau if she walk 5 meter or more. So
she prefer to sit down or lie down on the bed for long time. There was
no dyspneau in the night sleep and no need more than 1 pillow to sleep.
Because of prolonged rest on the bed, there are lesion on right bottom
and both of her elbow. In addition, she has been coughing for 4 months.
There is no sputum, only dry cough and she felt itchy in her throat. She
felt decrease of appetite because of she felt bad with her tounge and
painful when swallowing. Her daughter said that she got weight loss 10
kilogram for 4 months. She only defecate once for this 2 weeks.

SUMMARY OF DATA BASE

 Mrs. S/61yo/W22
Medical history : 2 months ago she was hospitalized at RS Batu because
of she felt fatigue. The doctor diagnose her with disease in lung, stomach and
liver. The cough had been slightly decrease and after 1 week, she was
outpatient and she felt the same complaint again. She felt decrease of
appetite, fatigue and was hospitalized again in RS Gondang Legi for 1 week.
she had been in the house for 3 weeks before she was going to emergency
department of RSSA.
Family history : There is no history of the same symptom as hers in her
family or neighborhood. She does not have history of DM, HTN , asthma
and allergy of food or medication. She also has not history for smoking and
drinking alcohol. She drinks jamu once a week and like to eat vegetable
Social history : She is a cane farmers. She always go to cane fields everyday
except Sunday from 6 am untul 12 pm. Her husband had been passed away 3
years ago and now she is living with her children. She has 2 daughters and 2
sons.

SUMMARY OF DATA BASE

PHYSICAL EXAMINATION
BP = 160/100 mmHg

PR = 88bpm, strong,
reguler

General appearance

looked moderately ill,

Bradipsiki, uremic foetor
(+)

Head

Anemic -

Neck

JVP R + 2 cmH2O 30

Thorax:

Cor:

Lung:

RR = 18 tpm

Tax : 36.7 C

GCS 456 Looks normoweight

Icteric -

ODS visus > 1/60

OD Subconjuntival
haemorrhage (+)

Invisible and palpable at ICS V MCL (S)

RHM SL Dextra
LHM Ictus
S1 S2 single murmur(-) gallop(-)
Simetric, SF D = S P s s A
--

v v

Rh

--

Wh

ss

bv v

++

ss

bv v

--+

---

LABORATORY FINDING
(11/5/2014)
Lab

Value

Leucocyte

18.46

Haemoglobine

(Normal)

Lab

Value

4.3-10.3
(103/uL)

Natrium

128

136-145 mmol/L

12,70

13,4-17,7
g/dl

Kalium

4.76

3,5-5,0 mmol/L

MCV

83

80-93 f

Chlorida

105

98-106 mmol/L

MCH

29.60

27-31 pg

RBS

148

< 200 mg/dl

PCV

35.60

40-47%

Albumin

3.92

3,5-5,5 g/dl

Trombocyte

543

142-424
(103/uL)

Ureum

74.90

10-50 mg/dl

Diff.count :
Eos/bas/neu/li
mf/mon

1.6/0.2/82 0-4/0-1/51- Creatinine

.1/10.3/5. 67/25-33/24
5
eGFR

2.69

< 1.2 mg/dL

SGOT

21

0-40 U/L

SGPT

19

0-41U/L

PPT
APTT

(Normal)

28.81

10.70
28.50

K. 11.1-11.6
K. 28.9-30.6

CXR

AP position, asymmetric, enough KV, enough inspiration

Trachea in the middle
Soft tissue and bone normal
Phrenico costalis angle dextra and sinistra are sharp
Hemidiaphragma dextra and sinistra are dome shape
Lung: BVN normal
Cor : site normal, CTR: 50%.
Conclusion : Within normal limit

CXR Mei 11th

2013

ECG

Sinus

Tachicardia, Heart rate 110 bpm

Frontal Axis
: normal
Horizontal Axis
: Clock wise rotation
PR interval
: 0,20
QRS complex
: 0.16
QT interval
: 0.32
Conclusion
: Sinus tachycardia 110x/minute

ECG

CUE AND
CLUE
Female/ 61 y.o.
General weakness
continously since 1
week ago
It would be
increased if she do
any activity and
relieved if she lied
down on bed
BP. 160/90
PR. 92
RT: reddish
fecal +, Mass
(+) 1-2 cm
Lab:
Hb 12.70
MCV 83
MCH 29.60

PL

IDx

1. Hemat 1.1 Lower GI

ochezi Bleeding
a
1.1.1
Hemorrhoids
interna
1.1.2
Diverticulosi
s
1.1.3
Malignancy

2. Dyspe 2.1 Gastritis

ppsia
2.2 PUD
syndro
me

PDx
Colonos
copy
USG
Abdom
en
FL,
FOBT

PTx
O2 2-4 lpm NC
IVFD NaCl 0,9% 30 dpm
Inj.Asam tranexamat 3x5 mg
(IV)

Inj.Omeprazoe 1x40 mg (IV)

If not available,ranitidin 2x 50
mg i.v

Pmo
Subj.
comp
lain
Bleed
ing
CBC

CUE AND CLUE

Male / 47 yo
History of
Hypertension (+)
History of
smoking (+)

PL

IDx

PDx

2. HT St-2

2.1 Ht
Primer
2.2 Ht
Secondary

3. CKD St
IV

3.1 Volume USG

depletion dt renal
No.I
3.2 Ht
Nephroscler
osis

USG
doppler
a.renali
s

PTx

Pmo

PO/
Amlodipin 1x5 mg (5-0-0)

Subj.
VS

IVFD NS 0.9% 30 dpm

Subje
ctive
comp
lain,
VS,
UOP,
ureu
m/cre
at,

VS :
BP (160/100
mmHg)

Male/47 yo
Nausea and
vomitting
History of Htn
since 30 years old
History of took
energy drink
Ureum 74.29
Creatinin 2.69
eGFR 28.81

Balance nol

CUE AND CLUE

Male / 47 yo
Dysuria
Polakisuria
History of Fever
(+)

PL
4.
Leukosito
sis

IDx
5.1
Infection
5.1.1 UTI
5.2
Reactive

PDx

PTx

Pmo

Inj.Ciprofloxacin 2x200 mg
(IV)

Subj.
VS.
Urine
Macro
s

C/ Neurology

Subjec
tive
compl
ain,
VS,
UOP,
ureum
/creat,

Lab :
Leukocyte 18,46
UL :
Nitrit (+)
Leukocyte +2
Bacteria
1311.1x103
Male/47 yo
History of CVA
thrombotic pons 3
weeks ago

5. History
of CVA
Thrombos
is pons

Thank you

Dx ; kolonoskopi, USG Abdomen, konsul ruangan neuro, UL, Lipid profile, As.Urat,
BGA, FL, FOBT,
Terapi :
O2 2 lpm NC
IVFD NaCl 0,9% 20 tpm
Insert NGT GL/8 jam 1 x bersih start diet cair 6x200 cc
Inj.Omeprazoe 1x40 mg (IV)
Inj.Asam tranexamat 3x5 mg (IV)
Inj.Ciprofloxacin 2x200 mg (IV)
Balance nol
PO/
Amlodipin 1x5 mg (5-0-0_
Monitoring :
Subj,VS,Perdarahan, Prod Urine, DL
KIE : Kondisi, rencana terapi, rencana diagnosis