MORNING REPORT

Tuesday , 5th of Desember 2017

Presented By :
Bethari Abi Safitri, S.Ked
Alifiana Aulia Rizki, S.Ked
Yulia Fitriani, S.Ked
Rahmadi, S.Ked

DOCTOR INCHARGE:
Dr. Dikara WS Maulidy, Sp.PD
 PATIENT IDENTITY

• Name : Mrs. S
• Sex : Female
• Age : 65 yo
• Religion : Budha
• Tribe : Banjar
• Nation : Indonesia
• Address : Pekauman 9 oktober RT.09/05 Banjarmasin
• Date of Hostipitalization : 04th December 2017
AUTOANAMNESIS
CHIEF COMPLAINT : HEADACHE

Patient complained about headache since the last 3 days. Patient

experienced headache without dizziness. Later, patient didnt
answer when being asked about her complained. Patient said she
felt very sleeppy and didnt want to answer. Patient also had
nausea and vomitted since the last 3 days. patient vomitted more
than 5 times a day. She will vomit after eating. Patient also
complained about shaking since the last 3 days. Patient looked
irritable and her answer didnt related to the question asked.
Patient admitted that she had diabetes melitus and
hipertension since couple years ago.She went to doctor and got
medicine. She used insulin and she arrange the dose by her self,
sometimes it’s 15 unit or 20 unit.
HETEROANAMNESIS

• History of past illness: unknown

• History of family illness: unknown
• History of drug: No drug abuse or addiction, patient
sometimes drinks alcohol
• Allergic History : No allergic history
• Smoking History: No smoking history
• Social History: Patient lives alone. She has a children’s and
family but no one cares with her.
PHYSICAL EXAMINATION
BP = 150/80 mmHg Pulse rate = 84 RR = 24 tpm Tax : 36,7 C
bpm
Regular, normal
General appearance looked mildly ill GCS E4V5M6
Head Pale conjungtiva (-) Icteric (-)
Neck JVP (-) lymph node enlargement (-)
Thorax: Cor: Ictus invisible, palpable at ICS V lateral MCL sin
LHM : Ictus RHM : ICS 3 PSL dextra
S1 S2 single, murmur (-)

Lung: Symmetric, S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen Flat, Bowel sound (+) normal, liver normal, splen normal, Murphy
sign (-), shifting dullnes (-), fluid wave (-), striac (-)
Extremities Pitting edema (-), cold acral (-), palmar and plantar icteric (-)
NEUROLOGICAL EXAMINATION

• Meningeal sign (-)

• Sensoric examination Normal
• Motoric examination Normal
• Physiologic reflex Normal
• Pathologic reflex (-)
LABORATORY RESULT
(MAY 4TH, DECEMBER 2017)
Test Result Range Units

HEMATOLOGY

Hemoglobin 12,4 12.00-16.00 g/dl

Leukocyte 12,6 4.00-10.5 thousand/ul

Erythroyte 4,00 4.00-5.30 Millionul

Hematocrit 35,4 37.00-47.00 Vol%

Trombocyte 404 150-450 Thousand/ul

RDW-CV 12,4 12.1-14.0 %

MCV, MCH, MCHC

MCV 88,5 75.0-96.0 fl

MCH 31,0 28.0-32.0 pg

MCHC 35,0 33.0-37.0 %

Leukocytosis
 Test Result Range Units

Deep Count

Gran% 81,6 50.0-70.0 %

Limfocytes% 13,6 25.0-40.0 %

MID% 4,8 4.0-11.0 %

Gran# 10,3 2.50-7.00 Thousand/ul

Limfocytes# 1,7 1.25-4.0 Thousand/ul

MID# 0,6 Thousand/ul

Glucose

Random Plasma Glucose 288 <200 Mg/dl

Liver

SGOT 72 0-46 U/l

SGPT 40 0-45 U/l

Kidney

Ureum 34 10-50 Mg/dL

Creatinine 1,4 0.6-1.2 Mg/dL

Increase of gran %, lymfopenia, hyperglichaemia, increase of SGOT
Items Result Normal Value

Natrium 107 135-146 mmol/l

Kalium 4.3 3.4- 5.4 mmol/l

Chlorida 75 95-100 mmol/l

Osmolarity = 2 ( Natrium + Kalium ) + (GDS/18) + (Ureum/6.4)

= 2 ( 107+4.3) + (288/18) + ( 34 : 6,4 )
= 243,9125 mOsm/L

Hypoosmolar hyponatremia
 Items Result Normal Value

Urinalysis
-Appearance Deep yellow Clear yellow
-Specific gravity 1.025 1.005 – 1.030
-pH 6.0 5.0-6.5
-Ketones Negative Negative
-Protein-albumin +2 Negative
-Glucose +1 Negative
-Bilirubin Negative Negative
-Blood +3 Negative
-Nitrite Negative Negative
-Urobilinogen 0.1 0.1-1.0
-Leukocyte Negative Negative
 Items Result Normal Value

Urinalysis (sedimen)
-White blood cells 2-3 0-3
-Red blood cells 15-20 0–2
-Silinder Negative Negative
-Epithel +1 +1
-Bacteria +3 Negative
-Crystals Negative Negative
-Others Negative Negative
CXR (DECEMBER, 4TH 2017
INTERPRETATION OF CXR

• Position AP
• Enough QV
• Enough inspiration
• No tracheal deviation
• Soft tissue and bone are normal
• Bronchovasculare pattern is normal
• No fibrosis
• Hemidiphragma dome shape
• Costophrenicus angle dextra and sinistra is sharp
• Cardiophrenicus angle dextra and sinistra is sharp
• CTR 58%
ECG (DECEMBER, 4TH 2017)
INTERPRETATION OF ECG

• Sinus, rhytem
• HR : 78 x/ m
• Frontal axis : normal axis
• Horizontal axis : normal axis
• PR interval : 0,16 s
• QRS duration: 0,08 ms
• T interval normal
• ST elevation (-)
• Conclution : normal
 POMR
CUE AND CLUE Problem IDx PDx PTx Pmo Ped
List
Female/65yo Severe After 20 Diet : low
hiponatremia NS 3% 150 ml during 20 minutes of 3% fluid
A minutes Admission,
Headache Ranitidine 2x50 mg evaluate the
Vomitus Purosemide 1x40mg sodium
Nausea
Weakness SE examination
irritable
Subjective
Laboratory Vital sign
Natrium 107 mmol/L
hypoosmolar

BUN : 15,88
CUE AND CLUE PL IDx PDx PTx Pmo Ped

Female/65 yo 2. Hypertension - - Nonfarmakologist : - Subject - Educational

A poorly treatment -Diet modification - Vital sign life style
-since couple years - Change lifestyle

ago, sometimes the Farmakologist :

blood pressure was Amlodipin 10 mg, 1
times/day (In the Morning)
high she even went
to the doctor if
none of other
symptoms like
headache.

PE:
•TD: 150/80
 CUE AND CLUE PL IDx PDx PTx Pmo
Female/33 yo 3. Diabetes - Non pharmachologist: • Subject • Diet
A Melitus - Diet modification specially • Vital sign nephrisol
Patient had diabetes for diabetic • HbA1C
melitus since couple - Always use sandal if she • Fasting plasma
years ago. out from house to protect glucose
the feet. • Post prandial
plasma glucose
Pharmachologist :
Laboratorium -Detemir Insulin 8 UI on
Random plasma night

glucose : 288