Saturday august 26th 2017

Physician in charge
June, Diane, Alvin

Moderator
dr. Dikara WS, Sp.PD
 Patient Identity

Name : Mrs. N
Sex : female
Age : 59 y.o
Religion : Islam
Tribe : Banjar
Nation : Indonesia
Address : JL Kuripan, Banjarmasin
Occupation :-
Date of Hospitalization : August 25st 2017 at 13.00 pm
 Autoanamnesis
Chief complained : Nausea
Autoanamnesis:

Patient complained of nausea and vomiting
since 1 week before hospitalized. Abdominal
pain at epigastric regio. The patient also
complained of faint because she didnt feel to eat.
The patient has a wound at her right and left legs
since 2 years ago, but hadnt treated well. The
patient had went to local govererment clinic but
refused to be treated at hospital. One week
before hospitalized, her thumb of right legs and
her left toes had been biten by mouse and get
some wound, and there are discharge at her toes.
 Autoanamnesis

History of past illness: -

History of family illness: DM (+) Father

History of drug: (-)

Allergic History : (-)

Smoking History: (-)

 Physical Examination (August 16st 2017 )
TD: 130/80 mmHg HR: 100 x/mnt reguler, RR : 30x/mnt reguler Tax : 36.6 0C SpO2 9
% 3 Lpm
General appearance : General moderate ill, kurus GCS 4-5-6
Head
Neck

Pale Conjungtiva (+), Sclera icteric (-)
JVP R+2 cmH2O, lymph node (-)
Thorax ( Pulmo ) I : Symmetric
Pal : Symmetric, Fremitus Sound D=S
Per : Sonor
A:VV Rh - - Wh - -
VV - - - -
VV - - - -
Cor I : Ictus Invisible
Pal : Ictus Palpable at ICS V MCL Sinistra
Per : LHM : ICS V MCL Sinistra
RHM : ICS IV Linea Sternalis
A: S1 S2 single, Murmur (-)
Abdomen Bowel sound (+) 10/ M, Hepatomegali(-), Spelonomegali (-),
Undulasi (-), Shifting Dullness (-)
Abdominal pain
---
---
+++

Extremities M 4 4 Pitting Edema - -

3 3 ++
From inspection :
Swallow (D), between the finger there is wound (D), pus (+),
odor (+)

Palpation : Warm (+). there is pultation in atreri dorsalis pedis,

tibialis anterior and arteri poplitea. Sensitivity of
monofilament in the leghs (-). Wagner : 2
 CXR
August, 18 th 2017

The result of CXR (02-08-2017)
Cor and Pulmo : Normal
Os Pedis : Normal
Ap position, enough KV, enough
inspiration
Soft tissue normal, bone normal
Trachea in the middle
Cor CTR :
Phrenico costalis Angle D : Sharp
Phrenico costalis angle S : sharp
Hemidiaphragma D/S : dome shape
Pulmo D/S : Normal
Conclusion : Normal
 BNO

August, 18 th 2017
Normal exam with Full Filled Bladder
 CT SCAN

August, 23 th 2017
Subacute cerebral infraction at substansia alba
periventrikuler and ganglia basalis bilateral
especially in the right side
 Laboratory Result 21-08-2017

Pemeriksaan Hasil Nilai Rujukan Satuan Metoda

HEMATOLOGI
Hemoglobin
Leukosit
Eritrosit
7,6
18,13
2,77

12,50-15,60
4,65-10,3
4,10-6,00
g/dl
thousand/ul
milion/ul
Colorimetric
Impedance
Impedance
Hematokrit 22,4 42,00-52,00 Vol% Analyzer Calculates
Trombosit 323 150-356 Ribu/ul Impedance
RDW-CV 12,3 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 81 75,0-96,0 Fl Analyzer Calculates
MCH 27,4 28,0-32,0 Pg Analyzer Calculates
MCHC 33,9 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 82.1 50,0-70,0 % Impedance
Limfosit% 9,3 25,0-40,0 % Impedance
Gran# 14.93 2,50-7,0 ribu/ul Impedance
Limfosit# 9,3 1,25-4,0 ribu/ul Impedance
 Pemeriksaanv Hasil Nilai Rujukan Satuan Metoda
GULA DARAH
GDP 121 70-105 MG/DL GOD-PAP
G2PP 119 <140 MG/DL GOD-PAP
HATI
albumin 1,73 3.5-5.5 g/dl Buret
IMUNO-SEROLOGI
AFP > 400.0 <10.0 Ul/ml 1-step EIA
sandwich + E
Ginjal
Ureum 171 10-50 Mg/dl Modiff berhelot
Creatinin 5,13 0,6-1,2 Mg/dl Jaffe
 18/8/2017
Pemeriksaanv Hasil Nilai Rujukan Satuan Metoda
GULA DARAH
GDP 215
70-105 MG/DL GOD-PAP
G2PP 229 <140 MG/DL GOD-PAP
IMUNO-SEROLOGI
Feritin >1200 <10-159 Ng/ml 1-step EIA
sandwich + E
 16/8/2017
Pemeriksaanv Hasil Nilai Rujukan Satuan Metoda
ELEKTROLIT
Natrium 127

135-146 Mmol/l Ise
Kalium 4,6 3.4 3.5 Mmol/l ISE
Chlorida 98 95-100 Mmol/l ISE
 Laboratory Result 16-08-2017

Pemeriksaan Hasil Nilai Rujukan Satuan Metoda

HEMATOLOGI
Hemoglobin
Leukosit
Eritrosit
9,2
18,5
3.39

12,50-15,60
4,65-10,3
4,10-6,00
g/dl
Ribu/ul
Juta/ul
Colorimetric
Impedance
Impedance
Hematokrit 26,2 42,00-52,00 Vol% Analyzer Calculates
Trombosit 620 150-356 Ribu/ul Impedance
RDW-CV 12,5 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 77,4 75,0-96,0 Fl Analyzer Calculates
MCH 27,1 28,0-32,0 Pg Analyzer Calculates
MCHC 35,1 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 84.3 50,0-70,0 % Impedance
Limfosit% 9,8 25,0-40,0 % Impedance
MID% 5.9 4,0-11,0 % Impedance
Gran# 15,60 2,50-7,0 ribu/ul Impedance
Limfosit# 1.8 1,25-4,0 ribu/ul Impedance
MID# 1,1 ribu/ul Impedance
 Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
GULA DARAH
GD Sewaktu 30 <200 MG/DL GOD-PAP
SGOT 13 0-46 U/l IFCC
SGPT
albumin
15
3.1 0-45
3.5-5.5
U/l
g/dl
IFCC
Buret
GINJAL
Ureum 92 10-50 mg/dl Modif-Berhelot
Creatinin 1,6 0,7-1,4 mg/dl Jaffe
 ECG

Sinus rhythm, regular, Heart rate 100x/m

Frontal axis: normal
Horizontal axis: clockwise rotation
PR interval : 0,12 seond
QRS complex : 0,1 second
QT interval : 0,4 second
Conclusion : sinus rytm
 CUE AND PL IDx PDx PTx PMo Ped
CLUE
Mrs. N/59 yo 1. Ane 1. Iron MDT, si, Ivfd Ns 0,9% 20 tpm DR
Ax: mia deficiency tibc, Fe inj. Omeprazole 1x40 mg
General weakness nor anemia Inj. Metoclopramide 3x10 mg
Nausea and mosi 2. Thalasemia

vomitting tik 3. Chronic
Px Fisik: nor diasease
Pale conjungtiva (+) mokr
Abdominal pain (+) omik
Lab: 2. Anor
Hb : 9,2 eksia
MCV : 77,4 geria
MCHC : 27,1 tri

Female/38 th 2. Debridement Personal

Ax: Diabetic and
Patient has a foot environm
lession on her foot ent
since 2 years ago hygiene
Physical Ex :
Wegner 2 (+)
Lab:
18.13 rb/ul
 Follow up

August, 21 th 2017:
S) The body of patient cant move
O) CM, BP 140/80, HR 82x/mnt, RR 20x/mnt, T 36.8oC
A) Diabetic Foot + DM tipe II + Anorexia geriatri
P) IVFD Nacl 30 tpm
inf ciprofloxacin 2x200 mg inj Lavemir 10 iu
inf metronidazole 3 x 500 mg inj citicolin 2 x 250
inj metoclopramid 3 x 10 mg
Inj Omeprazole 1 x 40 mg
p.o ASA 1 x 80mg
p.o Amlodipin 1 x 5 mg
 Follow up

August, 22 th 2017:
S) The body of patient cant move
O) CM, BP 140/100, HR 78x/mnt, RR 22x/mnt, T 37,0oC
A) Diabetic Foot + DM tipe II + Anorexia geriatri
P) IVFD Nacl 30 tpm
inf ciprofloxacin 2x200 mg inj Lavemir 10 iu
inf metronidazole 3 x 500 mg inj citicolin 2 x 250
inj metoclopramid 3 x 10 mg
Inj Omeprazole 1 x 40 mg
p.o ASA 1 x 80mg
p.o Amlodipin 1 x 5 mg
 Follow up

August, 23 th 2017:
S) The body of patient cant move
Fever
Cant intake oral
O) CM, BP 110/70, HR 83x/mnt, RR 24x/mnt, T 38.8oC
A) Diabetic Foot + DM tipe II + Anorexia geriatri
P) IVFD Nacl 30 tpm
inf ciprofloxacin 2x200 mg inj Lavemir 10 iu
inf metronidazole 3 x 500 mg inj citicolin 2 x 250
inj metoclopramid 3 x 10 mg inj Antrain 3 x 1 amp
Inj Omeprazole 1 x 40 mg
p.o ASA 1 x 80mg Consultasition to neurology
p.o Amlodipin 1 x 5 mg
 Follow up

August, 24 th 2017:
S) The body of patient cant move
Fever
intake oral (-)
O) Dellirium, BP 100/70, HR 94x/mnt, RR 26x/mnt, T 39.8oC
A) Diabetic Foot + DM tipe II + Anorexia geriatri
P) IVFD Nacl 30 tpm
inf ciprofloxacin 2x200 mg inj Lavemir 10 iu
inf metronidazole 3 x 500 mg inj citicolin 2 x 250
inj metoclopramid 3 x 10 mg inj Antrain 3 x 1 amp
Inj Omeprazole 1 x 40 mg Inf Paracetamol 3 x 1 flash
p.o ASA 1 x 80mg
p.o Amlodipin 1 x 5 mg
 Follow up

August, 25 th 2017:
S) The body of patient cant move
Fever
intake oral (-)
O) Coma, BP 90/60, HR 94x/mnt, RR 26x/mnt, T 39.8oC
A) Diabetic Foot + DM tipe II + Anorexia geriatri
P) IVFD Nacl 30 tpm
inf ciprofloxacin 2x200 mg inj Lavemir 10 iu
inf metronidazole 3 x 500 mg inj citicolin 2 x 250
inj metoclopramid 3 x 10 mg inj Antrain 3 x 1 amp
Inj Omeprazole 1 x 40 mg Inf Paracetamol 3 x 1 flash
p.o ASA 1 x 80mg
p.o Amlodipin 1 x 5 mg Instruction internist : Use Nasogastri Tube
 Follow up

09. 00 Am 10. 00 Am
Gcs 2-1-1 Gcs 2-1-1
TD : 90/60 TD : 80/70
HR : 112 HR : 120
T: 38,7
T : 38,0
SpO2 : 90 %
SpO2 : 92 %
Meningeal Sign (+)
Patient was feeded by her RH + + WH - -
family , after 30 minutes
++ --
her breathing sound was
eared gargling. ++ --
 Follow up

11.00 Am 12.00 Am
Gcs 2-1-1 Gcs 1-1-1
TD : 60/50 TD : 50/40
HR : 110 HR : 120
T: 39,00
SpO2 : 84 %
T: 38,7
Meningeal Sign (+) SpO2 : 78 %
RH + + WH - - Meningeal Sign (+)
++ -- RH + + WH - -
++ -- ++ --
We give the suction for the ++ --
patient
 13.00 Am

Patient passed Away
 At 5 am The Patient already has dicreased of concious and to
inform education to her family about patient condition
Patient are given an oxygen NRBM with O2 5 lpm

at 11 am, neurologist was visite and he already to inform
about patient condition, and the reason why the condition of
patient getting worst is aspiration

The patient was predicted passed away because shock septic

and aspiration at 1 am, 25 august 2017