MORNING REPORT

Wednesday, June 1st2011

PHYSICIANS INCHARGE:IA : dr. Asri, dr. Yuni, dr. Lowry IB : dr. Angga, dr RetnoII : dr. DidikIII : dr. Niniek Budiarti, SpPD-KPTI

Summary of Data BaseMrs Chayumi/51yo/W26

Chief Complain : leg swelling

Patient suffered from left leg swelling since 2 weeks before

admissio, worsening in the last 1 week, first she felt both leg was swollen but

now only left leg swollen accompanied with pain at her hip, stabbng like,

didn’t radiated (localized).

Patient also suffered from decreased of vision since 2 yeasr and

worsening in the last 2 weeks. She also often felt cold sweating, nausea,

sometimes vomiting and also epigastric pain since 2 years ago, intermittenly.

Summary of Data BaseShe had already checked at general practician and had been diagnosed as

Diabetes Mellitus type 2 since 7 years ago with RBS at that time was 350, she also

done abdominal USG. Got therapy Furosemide, Glimepirid, Ofloxacin and Antacida.

The last she consumed it was in 2 days ago and unroutinely controlled. Defecation

was in normal limit and urination was decreased but still often micturition.

She complained fever intermittenly and also cough with whitish sputum

in the last 2 months ago and got medication for it. She didn’t work anymore since 2

years ago.

Physical examinationBP = 120/70 mmHg PR = 112 bpm RR = 24 tpm Tax : 36.3 °C

General appearance looked moderately ill GCS 456

Head Pale conjunctiva + Cataract OD/OS +/+ visus hard to evaluate

Neck JVP R + 0 cmH2O

Chest Heart: Ictus invisible and palpable at MCL ICS V Sinistra LHM ≈ ictus, heart waist +RHM: SL DextraS1, S2 single with no murmur

Lung: Symetric, SF D = S, s s v v Rh - - Wh - - s s v v - - - - s s v v - - -

Abdomen liver span 10cm,troube space tympani, bowel sound (+) normalCatheter urine 1100cc/3hours

Extremities Anemi +/+ edema at left legA dorsalis pusation S hard to evaluate due to edema

Lab Value Lab Value

Leukocyte 24000 3.500-10.000/µL Natrium 116 136-145 mmol / L

Haemoglobine 5.0 11,0-16,5 g/dl Kalium 4.66 3,5-5,0 mmol / L

PCV 16.0 35-50% Chlorida 88 98-106 mmol / L

Trombocyte 747000 150.000-390.000/µL

RBSAlbumin

6503,5-5,5 g/dL

MCVMCH

7824.5

eGFRosm

16.86268

ml/mnt/1.73mosm

SGOT 14 11-41U/L Ureum 199.5 10-50 mg/dL

SGPT 16 10-41U/L Creatinine 3.15 0,7-1,5 mg/dL

Lab Value Lab Value

Urinalysis 10 x

SG 1.015 Epithelia +

PH 5 Cylinder -

Leucocyte - Hyaline -

Nitrite - Granular -

Protein + Leukocyte -

Glucose 4+ Erythrocyte -

Erythrocyte 5+ 40 x

Eritrosit 2-3

Keton urine + Leukocyte 3-4

Urobilinogen - Crystal +

Bilirubin - Bacteria -

BLOOD GAS ANALISIS

pH : 7.289pCO2 : 26.7 mmHgpO2 : 110.7mmHgHCO3 : 15.0mmol/LO2 sat : 97.5%BE : -14.2m mol/LConclussion : metabolic acidosis

ECG (//2011)Sinus rhythm, heart rate 102 bpm Frontal Axis : normalHorizontal Axis : normalPR interval : 0.20”QRS complex : 0.04”QT interval : 0.24”

Conclusion : sinus rhythm HR 102 bpm

CXR (//2011)

• AP position, asymmetric, enough KV, less Inspiration• Trachea in the middle• Soft tissue and bone normal• Hemidiaphragma D/S domeshape• Sinus prenicocostalis angle D/S sharp• Pulmo : infiltrate in both of the lung• Cor : CTR 57%, heart waist+

Conclusion: cardiomegaly

CUE AND CLUE PL IDx PDx PTx PMo

Female/51yoDM type 2 for 7 yearsBP 120/70mmHgPR 112tpmRR 24 tpmRBS 650 mg/dlOsm 268 mosmKeton urine +BGA : metabolic acidosisAnemia Normochrome NormocyterHb 5.0 MCV/MCH 74/24.5

1. Hyperglycemia state

1.1 KAD1.2 Mix with HHS

FBG/2hPP O2 2-4 lpm NC IVFD NS 0.9% 1000cc/2hoursActrapid 10 iu iv bolus if RBS >250Line I : Actrapid drip 5 iu/hour Line II : KCl drip 25meq in 500cc NS 10 tpmUntil RBS < 250Line I : Drip Actrapid 2.5iu/hourLine II : Drip KCl if RBS < 180Drip until 2 hoursPatient could eatDiet 1750ccal/dayInj Insulatard 0-10iuInj Actrapid 4-4-4iu

FBG2hPPRBS/hourElectrolyte serum/4 hoursBGA/6 hours

Female/61yoLeft leg swellingHip painEdema leg sinistra

2. Hip Pain 2.1 Fracture Patologic Pelvis Sinistra2.2 Musculosceletal disorder

Pelvis AP/Lateral

Inj Ketorolac 1 amp if pain

Painedema

Female/51yoLeft leg swellingEdema pitting leg sinistraABI score 1A dorsalis pedis S hard to evaluate

3. Leg swelling unilateral

3.1 Deep Vein Thrombosis

Doppler USG

Po ASA 1x80mg SubjectiveArterial pulsationEdema

Female/51yoDM type 2 7 yearsUr/Cr 199.5/3.15eGFR 16.86 ml/mnt/1.73Abdominal USG chronic parenchymatous renal disease

4. CKD stage IV 4.1 DM Nephropathy4.2 PNC

Abdominal USG

Regulate blood glucose firstFluid balance negative 500cc/dayKidney diet 1750ccal/day

Ur/CrVital signUrine production

Female/51yoTrombocyte 747000

5. Trombocytosis

5.1 Trombocytosis primary5.2 Trombocytosis secondary

Blood smear CBC (trombocyte)

Female/51yoNatrium 116Osm 268 mosmEdema +

6. Hyponatremia hypoosmolar hypervolemia

6.1 dilutional FE Na Fluid balance negative 500cc/day

Electrolyte serum

Female/51yoDecreased of vision OD/OSCataract OD/OS

7. Blurred vision OD/OS

7.1 Cataract senilis7.2 DM Retinopathy

Funduscopy Consult to Eye Department

Visus

Female/51yoPale conjunctiva +Hb 5.0 g/dlMCV 78MCH 24.5

8. Anemia Normochrome Normocyter

8.1 Chronic Diasease8.2 Low Intake

Blood smear, reticulocyte count

Transfussion PRC 1 kolf/day until Hb>8g/dl

CBC (Hb)

Female/51yoLow grade feverCough with withish sputum 2 mothsLeucocyte 24000

9. Chronic Lung Infection

9.1 Lung TB9.2 Bronchitis Chronis

Sputum cultura and sensitivity test

Inj Ceftriaxone 2x1g iv CoughT ax

Thank you