MORNING REPORT

August, 28th 2019

DESI MARNIWATI, 53 YO, HCU 08

 Cc: Breathlessness increased since 2 days ago

 Present illness history
 Breathlessness increased since 2 days ago, has been
felt since 2 weeks ago. Its increased when patient lay
down and felt when in the evening.
 Cough with greenish sputum since 7 days ago. Blood
(-)
 Fever (+) since 2 days ago, not high, no chill, no sweet
 Yellow appearance since 2 month ago
 Black stool since 2 days, but today (-)
 Liquid stool since 1 month ago, 2-3x/days, about ¼ of
glass, and accompany by colic abdomen.
PAST ILLNESS HISTORY
 History of DM (+), since 5 years, uncontrolled
 History of hypertension (+)

Family Illness History

No Family had symptoms like this patient.
 Consciousness level : CMC
 BP : 140/100 mmHg
 HR : 90 x/min, regular
 RR : 26x/min, fast and shallow
 T :37,2 ºC

Eyes : konjungtiva anemic (-) , sklera icteric(-),

Neck : JVP 5-2 cmH2O.
Lung :
- Insp : symetric, static and dynamic
- Palp : fremitus dextra = sinistra
- Perc : Sonor Dextra = Sinistra
- Ausk : bronchovesciculer, rhales (+/+), wheezing (-/-).
Heart
 Inspection: ictus is not seen
 Palpation: ictus is palpated at 1 finger lateral LMCS
ICS VI, ictus is 1 finger wide, no thrill
 Percussion:
Upper border: ICS II
 Right border: LSD

 Left border: 1 finger lateral LMCS ICS VI,

 Auscultation: normal (+) murmur (-)

Abdomen
- Insp : enlargement of abdomen (-),
- palp : liver palpated 1 finger bac &2 finger bpx, Spleen
palpated in S2
- Perc : tympani, shifting dullness (-)
- ausc : bowel sound (+) N
 Extremities : oedem (-/-), Physiologycal
reflex (+/+), pathological reflex (-/-).
LABORATORY FINDINGS

Hb 11,8 RBG 209

Ht 40 pH 7.31
L 6430 pCO2 21,1
Tr 309.000 pO2 141,4
HCO3- 10,8
Ur/kr 88/2,1 BE -15,7
Na/K/Ca/Cl 137/5,4/9,5/115 SO2 97,7
LABORATORY

Total Protein 7,3 gr/dl

Albumin 3,5 gr/dl

Globulin 3,8 gr/dl

Total Bilirubin 0,9 mg/dl

Direct Bilirubin 0,5 mg/dl

Indirect Bilirubin 0,4 mg/dl

SGOT 12U/L

SGPT 8 U/L
ECG
CXR
WORKING DIAGNOSE
 Hospitalized Acquired Pneumonia
 Acuute on CKD with metabolic acidosis and
Hyperkalemia
 CHF FC II LVH RVH sinus rhytm ec ASHD

 DM Type II Uncontrolled normoweight

 Cirrhosis hepatic Std Decompensated

DIFFERENTIAL DIAGNOSIS
 Hepatorenal Syndrome
THERAPHY
 Rest/ Soft Diet Low Salt, Heart diet II/ O2
3L/mnt
 IVFD Aminofuschin Hepar : NaCl 0,9%= 1:1, 12
hours/kolf
 Correction Meylon 150 mEq in 450 cc NaCl 0,9%
for 8 hours
 Inj cefepime 3x1 gram

 Inj Levofloxacine 1 x 500 mg  1 x 250 mg

 Nebu N acetyl cyctein/ 8 hours

 PCT 3x 500 mg
THERAPHY
 Gliquidone 1x30 mg
 Propanolol 2x 10 mg

 Spironolactone 2x 100 mg

 Inj Furosemide 1x 30 mg

 Kalitake 3x 1 sachet

 Bicnat 3 x 500 mgGabapentin 1x1 tab (PO)

 Fluid Balance
PLAN
- Sputum culture