MR 24B-ny endang (2).pptx

7/28/2019 MR 24B-ny endang (2).pptx

1/17

DR. YASMITA-PPDS

IPD

MORNING REPORT

May 28th,2012JAGA 1A : dr. Yasmita, dr. Daru , dr. Ungky

(paru)

JAGA 1B : dr. Ames , dr. Dyah

JAGA 2 : dr. Didin Retno

JAGA 3 : dr. Didi Candradikusuma, SpPDMODERATOR : dr. Niniek Budiarti, SpPD-KPTI


2/17

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 moreoften laying on bed.

Px also suffered from shortness of breath since 4days ago, esp when walked > 5 meters, often

couldnt slept in the night, and slept with 2 pillows.Px already complained about shortness of breathsince 1 year ago. Also complained about cough ,followed by low grade fever, without sputum.


3/17

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


4/17

PHYSICAL EXAMINATIONBP =140/80 mmHg PR = 100 bpm,

reguler

RR =24 tpm Tax : 37,4C

General appearance looked moderately ill GCS 456; looks overweight

Head Anemic +/+ Icteric -/-

Neck JVP R + 5 cmH2O

30

Thorax: Cor: Invisible and palpable at 2cm lateral ICS V MCL Sinistra

RHM SL Dextra

LHM ictus

S1 S2 single

Lung: Simetric, SF D = S, bv bv Rh + + Wh - -

bv bv + + - -

bv bv + + - -

Abdomen Soufle, BS (+) Liver span 10cm, traubes space thympani

Extermities Icteric-, edema -


5/17

LABORATORY FINDING

Lab Value (Normal) Lab Value (Normal)

Leukocyte 12600 3.500-10.000/L

Natrium 140 136-145mmol/L

Haemoglobi

ne

10.8 11,0-16,5g/dl

Kalium 4.37 3,5-5,0 mmol/L

PCV 31.6 35-50% Chlorida 110 98-106 mmol/L

Trombocyte

Neutrofil

Limfosit

233000

86.6%

9.7 %

150.000-390.000/L51-67 %25-33 %

RBS

Albumin

589

109

4.05

< 200 mg/dl

3,5-5,5 g/dl

MCV

MCH

83.3

28.6

80-96 fl

26,5-33,5 pg

Ureum

Creatinine

80.6

1.88

10-50 mg/dL

0,7-1,5 mg/dL

SGOT 99 11-41U/L eGFR 23.5 ml/mnt/1.73m2

SGPT 48 10-41U/L


6/17

URINALYSISLab Value Lab Value

10 x

SG 1.030 Epithelia +

PH 5.5 Cylinder -

Leucocyte - Hyaline -

Nitrite - Granular -

Protein 3+ Leukocyte -

Glucose 3+ Erythrocyte -

Erythrocyte 1+ 40 x

Erythrocyte 2-3

Keton urine 1+ Leukocyte 1-2

Urobilinogen - Crystal -

Bilirubin - Bacteria +


7/17

BGA

Temp 37.4 C O2

PH 7.51 7.35-7.45

PCO2 23.1 35 45 mmHg

PO2 147.0 80 100 mmHg

HCO3 18.6 21

28 m mol/L

O2 sat Art 99.3 > 95 %

BE - 4.6 (-3) - (+3) m mol/L

True o2 85.7

Conclusion : alkalosis respiratorik fully compensated with asidosismetabolic


8/17

CXR


9/17

CXR27/05/2012

AP position, asymmetric, enough KV, enoughinspiration

Trachea in the middle

Soft tissue and bone normal

Phrenico costalis angle dextra and sinistra are sharp

Hemidiaphragma dextra and sinistra are domeshape

Lung: infiltrat and air bronchogram at both of lung,

consolidation in upper and middle right lung.Cor : CTR : 68%.

Conclusion : cardiomegaly, pneumonia


10/17

ECG


11/17

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


12/17

CUE AND CLUE PL IDx PDx PTx PMo

Female/65 yo

Generalized weakness

Shortness of breath

Nausea vomittingHistory of DM since 10

years ago, never took

medicine in the last 6

months

PE:

BP. 140/80

PR.100RR. 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


13/17

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

2. DM type

II overweight

poorly

controlled

-Diet DM 1700 kkal/day, low salt


14/17


Female/65 yo

History of HT was

unknown (px never

check before)

PE:BP. 140/80

4.

Hyperte

nsion st I

4.1 primary HT

4.2 secondary

HT

-diet DM 1700 kkal/day, low salt

< 2gr/dl

-weight reduction

Subjec

tive

Female/65 yoUreum: 80.6

Creatinin: 1.88

BUN: 20.1

UOP. 25 cc/hour

5.Azotemi

a

prerenal

5.1. dt no 1 -Rehydration IVFD NS 0.9% SubjVS

ureu

Female/65 yo

Blurred vision since 5

years ago

History of DM since

10 years ago, not

routinely controlled

6.

Blurred

vision

6.1 DM

nephropathy

-Treat underlying disease

CUE AND CLUE PL Id PD PT PM


15/17


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. 140/80PR. 100

RR.28

cardiomegaly

UOP 25 cc/hour

CXR:

Cardiomegaly

ECG:

Sinus tachycardia

HR 100 bpm

7. HF st c

Fc II

7.1 diabetic

cardiomyopathy

7.2 HHD

Echocard

iografi

-O2 2-4 lpm

-semifowler position

-diet DM 1700 kkal/day, low salt

< 2gr/day

-Po: captopril 3x25mg

Subjec

tive

VS

UOP


16/17

THANK YOU


17/17

Condition this morning

Nausea +

BP. 150/90

PR. 96

RR. 20

UOP. 20 cc/hour

MR 24B-ny endang (2).pptx

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