MORNING REPORT

CASE

18th July, 2012

PATIENT’S IDENTITY
Name : IS
Age : 16 yo
Gender : Female
Ethnicity : javanese
Religion : Islam
Occupation: student
Address : jalan raya sesetan, denpasar
ToA : 17th July 2012 02.00 pm
 ANAMNESIS

 Chief complain :
fever
 Present history :

 Patient came with chief complained of fever

this morning BATH. The fever not getting better
with paracetamol.
 Patient also complained breathlessness this
morning BATH. And the breathlessness not
getting better with changing position. This
complained make patient felt weak.
 Vomit and nausea was denied. Cough was also
denied
 She had hospitalized 3 times in this year with
complained felt weak.
 Defecation and urination was normal.
 Past illness history
 patient had history of DM since she was 10 y.o

 History of kidney, heart, and liver disease was

denied
 Medication history

 Patient had insulin routine. She had novorapid

3x16 IU and levorapid o-o-o-18 IU
 Family history :
 None of the family member had the same
complained as the patient
 History of HT and DM was denied
 PHYSICAL EXAMINATION
General appearance : moderately ill
Level of consciousness : CM
GCS : E4V5M6
VAS : 0/10

Vital Sign:
 BP : 130/90 mmHg
 RR : 24 x/min
 PR : 140 x/min
 tax : 38,5°C
 BW : 50 kg BH : 150 cm BMI:
22,2kg/m2
Eyes : conj. Pale (-/-); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)

Neck : JVP RP 0 cmH2O;

lymph node enlargement (-)
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : dull/dull
Auscultation : Bronchovesikular + / + , Rh -/-, wh -/-
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tymphany
Palpation : liver, spleen unpalpable

Extremities: Warm +/+; edema -/-

+/+ -/-
 Complete blood count
Parameter Result Unit Remarks Reference range
WBC 30,12 103/μL H 4,5 – 11,00
-Ne 56,40% 16,98 103/μL 47,00 – 80,00
-Ly 33,80% 10,19 103/μL 13,0 – 40,0
-Mo 1,80% 0,54 103/μL 2,00 – 10,00
-Eo 0,40% 0,12 103/μL 0,00 – 5,00
-Ba 0,10% 0,03 103/μL 0,0 0 – 2,00
RBC 5,41 106/μL 4,50 – 5,90
HGB 15,10 g/dL 13,50 – 17,50
HCT 46,90 % 41,00 – 55,00
MCV 86,80 fL 80,00 – 100,00
MCH 27,90 pg 26,00 – 34,00
MCHC 32,10 g/dL 31,00 – 36,00
RDW 12,90 % 11,60 – 14,90
PLT 735,00 103/μL H 150,0 – 440,0
MPV 7,60 fL 6,80 – 10,00
 Blood chemistry panel

Parameter Result Unit Remarks Reference range

SGOT 53,00 U/L H 11,00 – 33,00
SGPT 53,00 U/L H 11,00 – 50,00
BUN 24,00 mg/dL H 10,00 – 23,00
Creatinine 0,96 mg/dL 0,50 – 1,20
BG 499,00 mg/dL H 70,00 – 140,00
Blood Gas analysis

Parameter Result Unit Remarks Reference range

pH 7,057 - 7,35 – 7,45
pCO2 10,30 mmHg L 35,00 – 45,00
pO2 123,30 mmHg H 80,00 – 100,00
HCO3- 2,80 mmol/L L 22,00 – 26,00

TCO2 3,20 mmol/L L 24,00 – 30,00

BE(B) -27,50 mmol/L L -2 – 2
SO2c 97,00 % 95,00 – 100,00
Natrium 131,00 mmol/L L 136,00 – 145,00
Kalium 5,30 mmol/L H 3,5 – 5,1
ECG
ECG
 Rhythm sinus
 Axis N
 ST-T change (-)
 Conclusion : sinus tachycardia (167x/mnt)
ASSESMENT

 DM susp Tipe 1
 Diabetic ketoacidosis
 Susp. infection
PLANNING
 Therapy
 Hospitalized
 O2 4 L/min

 Na Cl 0,9% 2000cc/ 2 hours  80 dpm. Na Cl 0,9% 30

dpm for 4 hours
 Cefotaxim 3 x I gr

 Paracetamol 3 x 500 mg

 Drip insulin 4 IU/hour in 500cc D5%  2 IU in 500cc D5%

 Drip natrium bicarbonat 100mg in Na Cl 0,9% 30 dpm

 Pdx
 FBG

2 hours post prandial

 A1C

 Lipid profile

 Monitoring
 Vital
sign
 BS @ hour

 K @ 6 hours

 BGA @ 6 hours
THANK YOU