1( Dr.

Herman)

Morning Report
th

Friday, September, 7 2012

Moderator :
Physician In Charge:
IA : dr. Herman, dr. Anshory, dr. Greg (cardio)
IB : dr. Yuni, dr. Rifai
II : dr. Hidayat
III : dr. Bogi, Sp.PD-KGEH

Summary Of Database:
Mrs Tiwar/77 Y.O/W 26

Chief Complaint: Shortness of Breath

Patient presented with the chief complaint shortness of breath since 2 days ago, previously SOB occur if walking more than
10 metres, sleeping with 2 pillows, and seldom awake at night due to SOB. It was also accompanied with productive cough,
white-yellowish sputum, and fever for 2 days. Chest pain (-). Pain when passing urine (-). Ulcer at skin (-).
She also complained of general weakness since 2 days ago.
History of past illness: DM and HT since 19 years ago. Unroutinely controlled. BP was about 160/.... until 200/.... mmHg.
Forgot medication she took.
Family History: No one in family that had DM, HT or cardiac disease.
Social History: She does household activities at home with no limitation.

Physical Examination
BP= 241/165 mmHg
PR= 113 bpm regular
General App.: looked severely ill

RR =32 tpm
GCS : 456
Looked underweight
Icteric sclerae (-)

Ax. Temp.= 36 C

Head
Neck
Thorax

Anemic conjunctiva (-)

Lnn. Enlargement (-)
0
JVP : R + 3 cm H2O; 30
Cor
Ictus invisible, palpable at 2 cm lat ICS VI, MCL S
RHM SL D
LHM ictus
S1, S2 single, no murmur
Pulmo
Symmetric; SF D=S; S| S V | V Rh - | - Wh - | S| S BV |B V
+| -| S| S BV |BV
+| +
-|-

Abdomen

flat, BS (N) normal, Liver span 10 cm, traubes space tympany, L/S unpalpable

Extremities

Edema (+)

2( Dr. Herman)

LABORATORY FINDINGS
LAB
RESULT
Leukocyte
13.800

NORMAL VALUE
3,500-10,000/L

LAB
Sodium

RESULT
136

NORMAL VALUE
136-145 mmol/l

Hemoglobine

12.30

11.0-16.5 g/dl

Potassium

4.65

3.5-5.0 mmol/L

MCV/MCH

87/28

Chloride

109

98-106 mmol/L

PCV

38

35-50%

RBS

682

>200 mg/dL

Thrombocyte

296.000

150,000-

Ureum

10-50 mg/dL

390,000/l

BUN/Creat

95.30
27.91

SGOT

17

11-41U/L

Creatinine

1.59

0.7-1.5 mg/dL

SGPT

23

10-41U/L

Albumin

3.77

3.5-5.5 g/dL

Diff count

03.3/0.2/33.9/54.6/7.8

PT

11.2
337

11.2

28.5

25

Eos/Ba/Neu/Ly/Mo
INR

Osm
1.00

URINALYSIS
SG
PH
Leucocyte
Nitrite
Protein
Glucose
Erythrocyte
Keton urine
Urobilinogen
Bilirubin

1.015
5.5
3+
+
2+
Trace
3+
-

aPTT

10 x
Epithelia Cylinder +
Hyaline GranularLeukocyte Erythrocyte 40 x
Erythrocyte uncountable
Leukocyte uncountable
Crystal
Bacteria

BGA:
pH

7.21

pCO2

50

pO2

159.5

HCO3

20.3

BE

-7.8

SaO2

99.0

Conclusion: Metabolic acidosis uncompensated

3( Dr. Herman)

CXR :
AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue normal, Phrenicocostalis
angle S/D sharp, Hemidiaphragm D/S domeshape, Pulmo: increased of broncho vascular shadowing, infiltrate on right
upper, middle, and lower, infiltrate on left basal lung Cor: site normal, size CTR about 65%, and shape normal.
Conclusion : Pneumoniae D/S + Cardiomegaly (LVH)

ECG:
Sinus rhythim, HR : 100 bpm
PR interval

: 0,12

QRS complex

: 0,08

QT interval

: 0,38

Frontal Axis

:N

Horisontal Axis

:N

S V2+RV5 > 35
Conclusion : sinus rhytim, HR 100 bpm, LVH

CUE&CLUE
Female/77 y.o
SOB
Sleep with 2
pillows
Productive cough
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Ictus palp 2 cm lat
MCL S ICS V
Rh +/+, BV/BV
Edema +
Leu 13.800
RBG
687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,
Nitrite +
BGA: metabolic
acidosis
CXR: pneumoniae

PL
1. ALO

IDx
1.1 Accelerated
hypertension
1.2 HF ST C Fc III

PDx
NT-proBNP

PTx
O2 NRBM 10 lpm
Semifowler position
Diet DM soft 1900 kcal/day,
low salt < 2 gram/day
IVFD NS lifeline
Furosemide 40-0-0
Po: ISDN 3x10 mg
Captopril 3x25 mg

PMo
S
VS

4( Dr. Herman)

+ cardiomegaly
ECG: LVH
Female/77 y.o
SOB
Sleep with 2
pillows
Productive cough
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Ictus palp 2 cm lat
MCL S ICS V
Rh +/+, BV/BV
Edema +
Leu 13.800
RBG
687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,
Nitrite +
BGA: metabolic
acidosis
CXR: pneumoniae
+ cardiomegaly
ECG: LVH
Female/77 y.o
SOB
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Ictus palp 2 cm lat
MCL S ICS V
Rh +/+, BV/BV
Edema +
Leu 13.800
RBG
687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,

2. Hypertension
Emergency

3. Hyperglicemic
Crisis

3.1 HHS
3.2 HHS mixed
KAD

Funduscopy,
Lipid profile, uric
acid

Antihypertension as above

S
VS

Plasma spesific
gravity
Serum keton

O2 8lpm NRBM
Inserted catheter, Fasting
Rehydration 2.5L of 0.9% NaCl
in 1 hour

Bolud rapid acting insulin

0.1iu/k 6iu (iv)
Line I: Rapid acting insulin
0,1iu/kgBW (6 iu)/hr IV
syringe pump
Line II: 0,9% NaCl 20 dpm

If blood glucose didnt

decrease 50-70 mg/dl in one
hour give 0.14iu/kg 9iu(iv)

Continue drip insulin

When serum glucose reaches
300mg/dl

Line I: Rapid acting insulin

0,05iu/kgBW (6 iu)/hr IV

Subjec
tive
BP
HR
RR
RBG/h
SE/4h
BGA/6h
Urine
production

5( Dr. Herman)

Nitrite +
BGA: metabolic
acidosis
CXR: pneumoniae
+ cardiomegaly
ECG: LVH

infusion
Line II: D50,45% NaCl

Keep the serum glucose

between 200-300mg/dl until
metabolic correction is
achieved

Long acting insulin 0-10iu (sc)

and Rapid acting insulin 4-44iu (sc,before
meal)continue iv Rapid
acting insulin infusion for 2
hours after sc insulin is begun

Female/77 y.o
SOB
Sleep with 2
pillows
Productive cough
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Ictus palp 2 cm lat
MCL S ICS V
Rh +/+, BV/BV
Edema +
Leu 13.800
RBG
687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,
Nitrite +
BGA: metabolic
acidosis
CXR: pneumoniae
+ cardiomegaly
ECG: LVH

4. HF St C FC III

Female/77 y.o
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32

5. Complicated UTI

4.1 HHD
4.2 CAD
4.3 DM
cardiomyopathy

Echocardiograph
y

Antihypertension as above

S
VS
Hb
Hematemesis
melena

Culture urine
and sensitivity

Levofloxacin 1x750 mg iv

S, VS

6( Dr. Herman)

T 36 C
Leu 13.800
RBG
687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,
Nitrite +
Female/77 y.o
SOB
Sleep with 2
pillows
Productive cough
Fever
General weakness
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Rh +/+, BV/BV
Leu 13.800
RBG
687
+
BGA: metabolic
acidosis
CXR: pneumoniae
+ cardiomegaly
Female/77 y.o
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
RBS 687
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
Female/77 y.o
History DM and
HT 12 years
BP 241/165
PR 113
RR 32
T 36 C
Ur/Cr 95.30/1.59
BUN/Creat 27.91
Osm 337
UL: Leu +3, Ery
+3, Prot +3,

6. Pneumoniae
CAP

Culture sputum
and sensitivity

7. DM type 2
underweight

8. Azotemia
prerenal

8.1 due to
dehydration
8.2 Cardiorenal
syndrome

Antibiotic as above
Ambroxol 3x30 mg

S, VS

Plan insulin after

hyperglicemic crysis resolved

Hba1c,
FBG/2hppBG,
target organ
damage

Treat underlying disease

S, VS, UOP,
Ur/Cr

7( Dr. Herman)

Nitrite +