mr 24b-ny endang (2).pptx
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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
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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.
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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
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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 -
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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
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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 +
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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
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CXR
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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
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ECG
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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
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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
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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
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CUE AND CLUE PL Idx PDx PTx PMo
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
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CUE AND CLUE PL Idx PDx PTx PMo
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
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THANK YOU
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Condition this morning
Nausea +
BP. 150/90
PR. 96
RR. 20
UOP. 20 cc/hour
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