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MORNING REPORT

Friday, 11 February 2011


PHYSICIAN INCHARGE:
IA : dr. Marthin, dr. Nicho
IB : dr. Tantri, dr. Endah
II : dr. Didik arief
III : dr. Djoko Heri, SpPD

Summary of database
Female / 79 yo / W.24A
Chief complaint : nausea and vomiting
Patient suffered from nausea and vomiting since 5 days ago, 4-5x/day
contain fluid and recidual food, not blood.
Patient also complained about shortness of breath since 2 months ago,
esspecially when activity (walk more then 10 meters) will relieved by rest.
not complaint about wake up in the night because of shortness of breath. She
can to sleep without pillow and not complaiened about shortness of breath.
Patient routine control on heart polyclinic RSSA because of shortness of breath
and palpitate and given furosemid, spironolactone, bisoprolol and digoxin.

Physical examination
BP = 90/60 mmHg PR = 90 bpm RR = 20 tpm Tax : 36.4 C
General appearance looked moderately ill; GCS : 456
Head Anemic ( - ) Icteric ( - )
Neck JVP R+ 2 cm H2O
Thorax cor Ictus invisible, palpable at 2 cm lat MCL (S) ICS V
S1 – S2 single, additional sound ( - )
lung Simetric, SF D = S, V V Rh - - Wh - -
V V - - - -
V V - - - -
Abdomen Flat, soft, BS (+) N, Epigastric pain (+), H/L unpalpable, liver span 10 cm,
troube space tymphani
Extremities Edema ( - )

Laboratory finding
Lab Value Lab Value
Leucocyte 9500 3500-10000/µL Na 136 136-145 Mmol / L
Hemoglobin 12.9 11,0-16,5g/dl K 5.8 3,5-5,0 Mmol / L
PCV 39.3 35-50% Cl 102 98-106 Mmol / L
Trombocyte 250.000 150000-390000 SGOT 31 11-41U/L
RBS 131 (<200)mg/dL SGPT 15 10-41U/L
Ureum 70.7 10-50mg/dL Alb 3.83 3.5 – 5.5 g/dl
Creatinine 2.03 0,7-1,5mg/dL

Urinelysis
BJ 1.010 PH 6 Glucose - Protein -
Nitrite - Leuco - Keton - Billirubun -
Erytro 0-2/hpf Leuco 1-2/hpf

CXR

AP position, asymetric, KV enough, enough inspiration, soft tissue and


bone normal, phrenico costalis angle on Right blunt and left sharp,
Hemidiaphragm D dome shape and left closed by cor shadow.
Lung : Infiltrates in the lower lung D/S
Cor : Side normal,Size CTR > 55 %,
 Conclution : Cardiomegaly and susp. Pneumonia

ECG
 Sinus Rhythm, HR 72 x/m
 Frontal Axis: Normal
 Horisontal Axis : CCWR
 PR interval : 0.20”
 QRS complex : 0.08”
 QT interval : 0.40’’
 Down sloping of ST Segmen
 Conclusion : Sinus rhythm with HR 72 bpm, suggestive of
digitalis intoxication

CUE and CLUE P. List I. Dx P. Dx P. Th/ P. Mo/


Female/ 79 YO 1. Dyspepsia 1.1 Drug Endoscopy IVFD NS 0.9% LL VS
Ax: syndrome induced (ASA) ASA and Digoxin STOP Clinic
Nausea and 1.2 Intoxication Omeprazole 2x20 mg po condition
vomiting of digitalis Inj. Metoclopramide 3x10 Complain
4-5 x/day since 5 1.3 PUD mg iv
days ago
History of heart
disease and
routinne control
and given
furosemid, ASA,
spironolactone,
bisoptolol and
digoxin since 3
months ago
PE:
BP 90/60, PR 90
RR 20 Ur 70.7 Cr
2.03
Epigastric pain

ECG :
Sinus rhythm
with HR 72
bpm,
suggestive of
digitalis
intoxication
Female/ 79 Yo 2. HF St C Fc III 2.1 HHD Echocardigraph O2 2-4 lpm NC VS
Ax: 2.2 CAD y Total fluid 1200 cc/hr Clinic
SOB when activity ( Heart diet 1700 kcal/day condition
walk more then 10 Captopril 3x6,25 mg po Complain
meters), routine Laxadin 3xC I
control in heart
polycliclinic
because of heart
disease and
palpitate and and
given furosemid,
ASA,
spironolactone,
bisoptolol and
digoxin since 3
months ago
PE:
BP 90/60, PR 90
RR 20
Ictus palpable at 2
cm lat MCL (S) ICS
V
ECG :
Sinus rhythm
with HR 72
bpm,
suggestive of
digitalis
intoxication

Female/ 79 Yo 3. Azotemia 3.1 Due to IUVD NS 0.9% LL VS


Ax : renal dehidration Clinic
Nausea and condition
vomiting Complain
Lab :
Ur 70.7
Cr 2.03

Female/ 79 Yo 4. 4.1 due to Corection hyperkalemia : SE


AX : Hyperkalemia dehidration Ca Gluconas 1 amp iv
Nausea and D40% 50 ml iv
vomiting Actrapid 10 unit iv
Lab :
K 5.8

Female/ 79 yo 5. Lung 5.1 Pneumonia Sputum Culture Inj. Ceftriaxone 2x1 gr iv VS


CXR : infection 5.1.1 CAP and sensitivity Clinic
Susp. Pneumonia test condition
Complain

THANK YOU