MORNING REPORT

PHYSICIAN IN CHARGE:
I A : dr. Nando , dr. Idham, dr. Vina
I B : dr. Etik dr. Lailatul, dr. Yasmitha
II : dr. Suyoso
III : dr. Rulli Rosandi, SpPD
MODERATOR : dr. BP Putra Suryana, SpPD-KR

Summary of Data Base

Darinah /70 y.o/w. 26
Chief

complain:

Decreased

of

consciousness

(Heteroanamnesis

her

daughter)
Patient presented with decrease of conciousness 3 days before admission.
The decrease of consiousnees happened gradually. At first, patient fell in
the bath room when she was cleaning the bath room. After she fell down
she can still go to the her room, but after that she can not freely moved.
After 2 days at home, she began to loose her apptetite, the ate only 1-2
spoon/day.
After 2 days, because the patient still feel weak (but she can still
communicated), she sent to hostpital.At the time the blood glucose is 580
mg/dl. Patient have history of diabetes melitius, uncontrolled. She

just

come to doctor if there she feel unwell. Before she feel unwell, the sons of
patient tell if there is no compllaint with her eat.

Summary of Data Base

Her weight body has been decreased since couple years ago. She was
hospitalized in prasetya hospital for 10 days. After 3 days, the patient
feel cant urinated, the colour urine is turbid yellow. After that she
was sent to hospital again and get catheter and the colour of urine is
also yellow. She sent to batu hospital for further examination and the
conclusion is she get renal infection. She reffered to RSSA
History of family: unremarkable.
Social history: married, having 4 children, a house wife, unroutinely
controlled for diabetes

PHYSICAL EXAMINATION

General appearance looked severely illness

GCS 223

Looked underweight

BP= 100/60
mmHg

PR = 92 bpm,regular

RR = 16 tpm

Tax = 36.5 0C

Head

Conjunctiva Anemic (-)

Sclera Icteric (-) cyanosis (-)
edema (-)

Pupil isocor (+)

3/3 mm

meningeal sign -

Neck

JVP R + 3 cm H20, 300 position

Lnn.
Enlargement (-)

Thorax
Heart

Ictus invisible & palpable at ICS V MCL S,

RHM ~PSL D, LHM ~ ictus
S1 S2 single regular, murmur ()

Lung

Symetric

Stem fremitus D=S

Sonor + +

Neck stiffness (-)

Rh + +

Wh - -

++

+ +

- -

+ +

- -

+
Abdomen

Flat , soefl, bowel Sound (+) N, Liver span 5 cm, traubes space
thympany shifting dullness +

Extremitiey
Skin

Edema Contractur
+ +
+ +

Warm acral

RF 1 1 Motoric 3 3 RP B/C/O/G/T :
-/-/-/-/1 1
3 3
MS (-),

LABORATORY FINDINGS
Lab
Leucocyte
Diff count

Haemoglobin

Value
23310

4000-11.000/L

124

136-145mmol/l

1.99

3,5-5,0 mmol/l

11-16,5 g/dL

Cl

91

98-106 mmol/l

MCV

80.70

80-93 fl

Ureum

MCH

27.80

27-31pg

Creatinin

PCV

34.80

40-47 %

Thrombocyte

401000

Value

Na

0.1/0.1/9 0-4/0-1/514.5/3.5/1. 67/25-33/2-5 %

5
12.0

Lab

150-450x103/L

11.30
0.29

16,6-48,5 mg/dL
< 1,2 mg/dL

Inr

0.97

RBS

187

< 200 mg/dL

SGOT/AST

17

11-41U/L

PPT

10.90

(11.1-11.6)

SGPT/ALT

11-41U/L

APTT

30.30

(28.9-30.6)

Osmolarit
as

273

URINALISIS
Lab

Value

Lab

Value

Cloudy

claudy

Clear

10 x

Color

yelow

Yellow

Epitel

1lpf

4,5 - 8,0

Cilinder

Lpf

1,010 1,015

Hialin

2
Negative

pH

7.0

BJ

1.015

Glucose

+1

Negative

Granular

Protein

trace

Negative

40 x

Keton

Negative

Erythrocyte

Bilirubin

Negative

Dysmorfic

Hpf

Urobilinogen

Negative

Eumorfic

Hpf

Nitrit

Negative

Leucocyte

Leucocyte

+2

Negative

Cristal

Blood

+2

Negative

Bacteria
Others

205

3 hpf

5 hpf
hpf

1615

23 x 103/mL

BLOOD GAS ANALYSIS (NRBM

10L/M)

BGA

Value

Normal Value

PH

7.57

7,35-7,45

PCO2

35.2

35-45 mmHg

PO2
True O2 :

146.7

80-100 mmHg

HCO3

32.8

21-28 mmol/L

Base Excess

10.7

-3 until +3 mmol/L

O2 saturation

98.5

> 95%

Conclussion

Metabolic alcalosis

ECG

ECG

Sinus rhythm, Heart rate 100 bpm

Frontal Axis
: Normal
Horizontal Axis
: Normal
PR interval
: 0,12
QRS complex
: 0,08
QT interval
: 0,32

Conclusion : sinus tachycardia with HR 100 bpm

CXR

Chest X-Ray
AP position, asymmetrical, KV enough, less
inspiration
Soft tissue thin, Bone normal
Trachea in the middle
Hemidiaphragm D /S is dome shape
Phrenico cotalis angle D/S is sharp
Pulmo D/S : fibroinfiltrat upper area lung D & S
Cor site N, size : CTR 50 %
Conclusion : lung TB,pneumonia

POMR
Cue and Clue

Male/41yo/ w26
Ax:
Decrease of
conciousness
Nausea and
vomiting
Wound in left
foot
PE:
GCS 223
BP: 130/90
mmHG
PR: 105 bpm
RR 26 tpm
Ronkhi + all
over lung area
Rash all over the
body
Lab:
Leuko 150/uL
Blood smear:
normochrom
normocytic,
leucocyte looks
so decrease,
trombosit looks

Problem
List

1. DOC

Initial
Diagnosa

Planning
Diagnosa

1.1.sepsis
1.1.1 skin
infection
1.1.2
diabetic
foot
.2
scabies?

Blood
culture
and
sensitivit
y

1.2. CVA

Planning Teraphy

Bed rest
O2 8-10 lpm/mnt NC
Insert NGT
fluid diet 6 x 100cc
Insert catheter urine
Equal Fluid balance
IVFD NaCl 0.9% 20 dpm
Infus ciprofloxacin 2 x 400
mg IV
Per NGT:
Clindamycin 3 x 300 mg

Planning
Monitoring &
Education

S, VS, UOP

POMR
Cue and Clue

Male/41yo/ w26
Ax:
DOC
Sufferd liver
cirrhosis
PE:
GCS 224
Rhonki + all
area of the lung
Rash all over the
body
Wound at left
foot
Lab:
Leuko 25740
Bil T/D/I:
45.84/32.20/13.
64
Albumin 3.03
g/dL
UL:
Leukocyte: 8.5
HPF
Bacteria:

Problem
List

2. Sepsis

Initial
Diagnosa

2.1 skin
infection
2.1.1
diabetic
foot
2.1.2
scabies?
2.2
pneumoni
a
2.3 UTI

Planning
Diagnosa

Blood,
sputum,
urine
culture
and
sensitivit
y test
Gram
scraping

Planning Teraphy

Bed rest
O2 NRBM 10 L/m
Equal fluid balance
Inserted NGT and catether
Liquid diet 6 x 100 cc
IVFD NaCl 0.9% 20 dpm
Infus ciprofloxacin 2 x 400
mg IV
Per NGT:
Clindamycin 3 x 300 mg
Wound toilet and
debridemant

Planning
Monitoring &
Education

S, VS, UOP

Male/41yo/ w26
Ax:
Newly
diagnosed DM
Wound at left
foot since a
month ago
PE:
Pulsation: strong
arteri dorsalis
pedis
Extent: 5-8 cm
Depth: dermis
Infection: pus,
blood
Sensoris: normal
ABI score: 1.0
Lab:
Leuko 150

3.
Diabetic
foot
wagner II

POMR

Mechanical and educational

control:
Use thick and soft soles
sandals and shoes
Microbiological:
perNGT: clindamycin 3x300
mg
Metabolic control:
Plan for insulin
Vascular control:
Plan for arteriography and
USG Doppler
Wound control:
debridement and wound
dressing

Education

S, VS, UOP
Left pedis Xray

POMR
Cue and Clue

Male/41yo/ w26
Lab:
Na 125 mmol/L
K 3,14 mmol/L
Osmolaritas 273
mmol/L

Problem
List

Initial
Diagnosa

4.Hponatr
emia
hypoosm
olar
hypovole
mia

3.1
dehydratio
n
3.2 poorly
intake

Planning
Diagnosa

Plasma
spesific
gravity

Planning Teraphy

Rehydration 1470 cc, 770

cc in 1-2 hours and
continued with 770 cc in 3
hours and than
maintenance 20 dpm

Planning
Monitoring &
Education

S, VS, UOP

POMR
Cue and Clue

Problem
List

Initial
Diagnosa

Planning
Diagnosa

Planning Teraphy

Planning
Monitoring &
Education

Male/41yo/ w26
Lab:
Leuko 150
RBC 3 x 106

5.
Bisitopeni
a

4.1dt
septic
5.2 MDS
5.2.
anemia
aplastic

Blood
smear
BMP

Confirm diagnosed

S, VS, UOP

Male/41yo/ w26

6.Lung
infection

6.1
pneumoni
a
1.2 tb with
secunder
infection

Fast acid

As above

Subjective
VS

Rhonki all area of

the lung
Lab:
CXR:
fibroinfiltrat

POMR
Cue and Clue

Male/41yo/ w26
Ax:
Suffered from
diabetes
Decrease of body
weight
Polyuri
Polydipsi
PE:
Mucle atrophy
Dry skin

Problem
List

Initial
Diagnosa

Plannin
g
Diagnos
a

8. DM
type 2
newly
diagnose
d

Planning Teraphy

Planning
Monitorin
g&
Educatio
n

Plan for insulin therapy

S
VS
FBG
PP2HBG
HbA1c

Confirm diagnose

Subjective
VS

LF:
RBS: 137mg/dL

Male/41yo/ w26
Ax:
Ichy all over the
body
PE:
rash all over the
body, crustae,
ichy,
painless,canalliculi

9. Skin
rash

9.1
Scabies
9.2
Streptoc
occal
infection

Gram
scrappin
g

UTI
Pneumonia

Sepsis

DOC

DM type 2

Skin
infection

Bicitopeni

Risk Factor of Sepsis

Very young people and elderly people
Anyone who is taking immunosuppressive medications (such
as transplant recipients)
People who are being treated with chemotherapy drugs or
radiation
People who have had their spleen surgically removed (the
spleen helps fight certain infections)
People taking steroids (especially over the long term)
People with longstanding diabetes, AIDS, or cirrhosis
Someone who has very large burns or severe injuries
People with infections such as

pneumonia,
meningitis,
SBP
cellulitis,
urinary tract infection

Management Analysis
Bed rest
O2 8-10 lpm/mnt NC
Insert NGT
fluid diet 6 x 100cc
Insert catheter urine
Rehydration 1470 cc, 770 cc in 1-2 hours and
continued with 770 cc in 3 hours and than
maintenance 20 dpm
Equal Fluid balance
IVFD NaCl 0.9% 20 dpm
Infus levofloxacin 1 x 400 mg IV
Inj gentamycin 2 x 40 mg iv
Per NGT:
Clindamycin 3 x 300 mg

Mechanical and educational control:

Use thick and soft soles sandals and shoes
Microbiological:
perNGT: clindamycin 3x300 mg
Metabolic control:
Plan for insulin
Vascular control:
Plan for arteriography and USG Doppler
Wound control:
debridement and wound dressing

Condition Patient This

Morning

GCS
BP
PR
RR
Tax

: 223
: 130/80mmHg
: 88 bpm
: 22 tpm
: 36 0C

THANK YOU