DR.

YASMITA-PPDS IPD

MORNING REPORT May 28th,2012

JAGA 1A : dr. Yasmita, dr. Daru , dr. Ungky (paru) JAGA 1B : dr. Ames , dr. Dyah JAGA 2 : dr. Didin Retno JAGA 3 : dr. Didi Candradikusuma, SpPD MODERATOR : dr. Niniek Budiarti, SpPD-KPTI

SUMMARY OF DATA BASE

Mrs. Endang/65 yo/W24B Chief complain: generalized weakness Px suffered from generalized weakness since the last 1 year ago, but worsening in 4 days. Px more often laying on bed. Px also suffered from shortness of breath since 4 days ago, esp when walked > 5 meters, often couldnt slept in the night, and slept with 2 pillows. Px already complained about shortness of breath since 1 year ago. Also complained about cough , followed by low grade fever, without sputum.

She complained about nausea since 4 days ago, sometimes followed with vomit, bloating sensation, and made her loss of appetite, even more she couldnt ate anything in the last 4 days. Px also suffered from blurred vision since 5 years ago, in left eye couldnt saw anything. had a history of DM since 10 years ago, ever consumed glibenclamide, but didnt took medicine since 6 months ago. Family history: mother and father had DM

PHYSICAL EXAMINATION
BP =140/80 mmHg PR = 100 bpm, reguler RR =24 tpm Tax : 37,4C
General appearance looked moderately ill Head Neck Thorax: Cor: Anemic +/+ JVP R + 5 cmH2O 30 Invisible and palpable at 2cm lateral ICS V MCL Sinistra RHM SL Dextra LHM ictus S1 S2 single Simetric, SF D = S, bv bv bv bv bv bv Rh + + ++ ++ Wh - --GCS 456; looks overweight Icteric -/-

Lung:

Abdomen Extermities

Soufle, BS (+) Liver span 10cm, traubes space thympani Icteric-, edema -

LABORATORY FINDING Lab Value (Normal) Lab Value

Leukocyte Haemoglobi ne PCV Trombocyte Neutrofil Limfosit MCV MCH 12600 10.8 31.6 233000 86.6% 9.7 % 83.3 28.6
3.50010.000/L

(Normal) 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L < 200 mg/dl 3,5-5,5 g/dl 10-50 mg/dL 0,7-1,5 mg/dL

Natrium Kalium Chlorida RBS Albumin Ureum Creatinine

140 4.37 110 589 109 4.05 80.6 1.88

11,0-16,5 g/dl 35-50% 150.000390.000/L 51-67 % 25-33 % 80-96 fl 26,5-33,5 pg

SGOT
SGPT

99
48

11-41U/L
10-41U/L

eGFR

23.5

ml/mnt/1.73 m2

URINALYSIS
Lab SG PH Leucocyte Nitrite Protein
1.030 5.5 3+ 3+ 1+

Value

Lab 10 x
Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x Erythrocyte

Value
+ -

Glucose
Erythrocyte Keton urine Urobilinogen Bilirubin

2-3
1-2 +

1+ -

Leukocyte Crystal Bacteria

BGA
Temp PH PCO2 PO2 HCO3 O2 sat Art BE True o2 37.4 C 7.51 23.1 147.0 18.6 99.3 - 4.6 85.7 O2 7.35-7.45 35 45 mmHg 80 100 mmHg 21 28 m mol/L > 95 % (-3) - (+3) m mol/L

Conclusion : alkalosis respiratorik fully compensated with asidosis metabolic

CXR

CXR 27/05/2012
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: infiltrat and air bronchogram at both of lung, consolidation in upper and middle right lung. Cor : CTR : 68%. Conclusion : cardiomegaly, pneumonia

ECG

ECG

Sinus rhytm, Heart rate 100 bpm Frontal Axis : Normal Horisontal Axis : Normal PR interval : 0,12 QRS complex : 0,09 QT interval : 0,36 Conclusion : sinus rhytm HR 100 bpm

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/65 yo Generalized weakness Shortness of breath Nausea vomitting History of DM since 10 years ago, never took medicine in the last 6 months PE: BP. 140/80 PR.100 RR. 24 Lab: RBS 589109 pH 7.42 HCO3 18.4 Osmolarity 294.8 Anion gap 15.97 UL: glucose 3+ keton 1+

1. Post hyperglyc emia crisis

1.1 HHS 1.2 Mixed HHS and KAD

O2 2-4 Lpm via NC Rehydration 2-3L of NS 0,9% over first 1-3h Actrapid 10iu (iv) Line I:drip actrapid 50iu in 250mL NS 0,9% 25 mikrodrip/mnt5iu/h Line II:drip KCl 30mEq in 500mL NS 0,9% 10 dpm Until RBG<250 Line I:drip actrapid 50iu in 250mL D51/2NS 12 mikrodrip/mnt2,5iu/h Line II:drip KCl 30mEq in 500mL NS 0,9% 10 dpm Until RBG<200 Giving subcutaneous insulin: *Insulatard 0-10iu *Actrapid 4iu-4iu-4iu Stop insulin and KCl drip after 2 hoursNS 0,9% Lifeline

Subjecti ve BP HR RR BW SE

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Female/ 65 yo History of DM since 10 years ago, never took medicine in the last 6 months Lab: RBS 589109 Female/65 yo Cough 4 days, without sputum Low grade fever Shortness of breath PE: BP. 140/80 PR.100 RR. 24 Rales at lung dextra and sinistra Lab: Leuco:12.600 Neutrofil:86.6% CXR: Infiltrate, airbronchogram

2. DM type II overweight poorly controlled

-Diet DM 1700 kkal/day, low salt <2 gr/dl -inj. Insulatard 0-0-10 iu sc -inj. Actrapid 4-4-4 iu sc

Subjec tive, FBS, 2HPP

3. Acute lung infection

3.1 Pneumonia CAP PS: 115 (CURB65:1)

Sputum gram, culture, sensitivi ty test Blood culture

-O2 2-4 Lpm via NC -Inj. Ceftriaxone 2x1 gr -inj. Ciprofloxacin 2x200 mg (adjusting dose)

Subjec tive, VS, Leucos it, CXR

CUE AND CLUE

Female/65 yo History of HT was unknown (px never check before) PE: BP. 140/80

PL

Idx

PDx

PTx
-diet DM 1700 kkal/day, low salt < 2gr/dl -weight reduction

PMo
Subjec tive

4. 4.1 primary HT Hyperte 4.2 secondary nsion st I HT

Female/65 yo Ureum: 80.6 Creatinin: 1.88 BUN: 20.1 UOP. 25 cc/hour Female/65 yo Blurred vision since 5 years ago History of DM since 10 years ago, not routinely controlled

5. Azotemi a prerenal 6. Blurred vision

5.1. dt no 1

-Rehydration IVFD NS 0.9%

Subj VS ureu

6.1 DM nephropathy

-Treat underlying disease

CUE AND CLUE

Female/65 yo Shortness of breath Paroxysmal nocturnal dyspneu SOB when walked >5 meters History of DM since 7 years ago History of HT unknown PE: BP. 140/80 PR. 100 RR.28 cardiomegaly UOP 25 cc/hour CXR: Cardiomegaly ECG: Sinus tachycardia HR 100 bpm

PL

Idx

PDx
Echocard iografi

PTx
-O2 2-4 lpm -semifowler position -diet DM 1700 kkal/day, low salt < 2gr/day -Po: captopril 3x25mg

PMo
Subjec tive VS UOP

7. HF st c 7.1 diabetic Fc II cardiomyopathy 7.2 HHD

THANK YOU

Condition this morning

Nausea + BP. 150/90 PR. 96 RR. 20 UOP. 20 cc/hour