MORNING

REPORT

dr.Hengki-PPDS IPD

January 01st 2013

PHYSICIANS INCHARGE:
IA : dr. Hengki, dr. , dr. (Cardio)
IB : dr. , dr.
II : dr.
III : dr., SpPD-K
MODERATOR : dr., SpPD-K

Summary of Data Base

Mr. / y.0/ w.
Chief complain:
Patient suffered from

Summary of Data Base

Physical examination
ER BP: mmHg
Ward BP: mmHg

ER PR: bpm
Ward PR: bpm

ER RR: tpm
Ward RR: tpm

General appearance looked ly ill

ER GCS:
Ward GCS:

Head

Pale conjunctiva ( - )

Icteric sclera ( - )

Neck

JVP R+ cmH2O position 30 deg

Chest

Heart:

Lung:

ERTax: C
Ward Tax: C

Ictus invisible and palpable at

LHM ictus RHM: SL D
S1, S2 single, murmur ( - )
Symmetric, SF D=S, P s s Ausc v v Rh - - Wh - ss
vv
--ss
vv
---

Abdomen

Soefl, bowel sound (+) normal, tenderness , liver span cm,

traubes space tympani, shifting dullness ( - )

Extremities

Acral warm, leg edema + / +

ABI Score: D/
S/
Rectal touche:Insp: mass (-)
Palp: tonus sphincter ani (+) N, mucousa smooth
Prostate: consistency ;sulcus mediana ;lateral
pole ;superior pole ;bulbus cavernosus reflex

LAB

VALUE

(NORMAL)

LAB

VALUE
(NORMAL)

Hb

11,0-16,5 g/dL

Natrium

136-145
mmol/L

MCV

80-96 f

Kalium

3,5-5,0
mmol/L

MCH

26,5-33,5 pg

Chlorida

98-106
mmol/L

Leucocy
te

3.50010.000/L

RBS

< 200 mg/dl

Eos / Bas / Neu / Limf / Mon

Ureum

10-50 mg/dL

0/0/ / / %

Creatinine

0,7-1,5
mg/dL

RDW

11,5-14,5 %

BUN/Cr

PCV

35-50 %

eGFR

ml/mnt/1.73
m2

Plt

150.000390.000/L

SGOT

11-41U/L

ESR

mm/h

SGPT

10-41U/L

PPT

K: second

Albumin

3,5-5,5 g/dL

APTT

K: second

Bilirubin Total

< 1 mg/dL

LAB

VALUE

(NORMAL)

LAB

VALUE
(NORMAL)

Fe

53-167 g/dL

Ca

7,6-11
mg/dL

TIBC

300-400 g/dL

2,7-4,5
mg/dL

SI

HbA1C

4,5-7

CEA

< 5 ng/mL

Anti Dengue
IgG

Negative

AFP

7 ng/mL

Anti Dengue
IgM

Negative

CA 19-9

< 37 U/mL

Determine
HIV

Non reactive

ALP

66-220 U/L

Bioline HIV

Non reactive

Oncoprobe

Non reactive

URINALYSIS
LAB
Urinalysis
PH
SG
Glucose
Protein
Keton
Bilirubin

VALUE

LAB

VALUE

10 x
Epithelia
Cylinder

lpf

Hyaline

lpf

Granular

lpf

Leukocyte

lpf

Erythrocyte

lpf

Urobilinogen

40 x

Nitrite

Erythrocyte

hpf

Leucocyte

Leukocyte

hpf

Erythrocyte

Crystal

hpf

Bacteria

X 103/mL

BGA
TEMP

O2 L/M

PH

7.35-7.45

PCO2

35 45 mmHg

PO2

80 100 mmHg

HCO3

21 28 m mol/L

O2 sat Art

> 95 %

BE

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

True o2
Conclusion :

BLOOD SMEAR
ERYTHROCYTE:
LEUCOCYTE:
THROMBOCYTE:

FECAL SMEAR

FECAL SMEAR
LAB

VALUE

NORMAL

LAB

VALUE

NORMAL

Colour

Residual
food

Shape

Muscle
fibers

<10

Epithel

Negativepositive 1

Plants
fibers

-/+

Leucocyt
e

Amylum

-/+

Erythrocy
te

Negative

Fat

Steatorhoe
>60

Parasite
Egg worm

Negative

Larva

Negative

Trophozoi
te

Negative

Cyste

Negative

ASCITES FLUID ANALYSIS

LAB

VALUE

NORM
AL

LAB

VALU
E

NORMAL

Macroscopic

Protein Total

< 3 g/dL

Colour

Glucose

> 60 mg/dL

Clot

Trigliserida

Chylous >110 mg/dL

Pseudochylous <50
mg/dL

Clarity

Cholesterol

Transudat >45-60
mg/dL
Exudat <45-60 mg/dL

Microscopic

LDH

Transudat <320 U/L

Exudat >320 U/L
Negative

Erythrocyte
count

/L

Rivalta Test

Leucocyte
count

/L

Albumin
Serum

PMN

Albumin
Ascites

MN

SAAG

ECG

ECG
Sinus rhythm, heart rate bpm
Frontal Axis
:
Horizontal Axis
:
PR interval
:
QRS complex
:
QT interval
:
Conclusion :

CXR

CXR

AP position, asymmetric, enough KV, enough Inspiration

Trachea in the middle
Soft tissue and bone normal
Hemidiaphragma D/S (domeshape/ domeshape)
Sinus prenicocostalis angle D/S (sharp/sharp)
Pulmo : bronchovesicular pattern increase, infiltrat
Cor : site N, shape, cardiac waist, CTR %

Conclusion:

BOF

BOF
Preperitoneal fat line D/S normal
Psoas shadow D/S simetric
Countour kidney D/S covered by bowel air
Countour hepar & lien normal
Distribution of bowel air spread evenly with fecal inside
Visible ground glass at cavum pelvis
Unseen radioopaque shadow at urinary tract
Conclusion:

CUE AND CLUE

Male / yo
A
PE
LAB

Male / yo
A
PE
LAB

PL

IDx

PDx

PTx

PMo

CUE AND CLUE

Male / yo
A
PE
LAB

Male / yo
A
PE
LAB

PL

IDx

PDx

PTx

PMo

CUE AND CLUE

Male / yo
A
PE
LAB

Male / yo
A
PE
LAB

PL

IDx

PDx

PTx

PMo

CUE AND CLUE

Male / yo
A
PE
LAB

Male / yo
A
PE
LAB

PL

IDx

PDx

PTx

PMo

CUE AND CLUE

Male / yo
A
PE
LAB

Male / yo
A
PE
LAB

PL

IDx

PDx

PTx

PMo

Problem analysis
History of Hypertension

Heavy Smoker

CAD

HHD

Peripheral Artery Disease

Precipitating factor

Using of Aspirin
Bad Compliance
pneumonia

HF st C Fc
IV
Melena

Hypercatabolic state
Hypoalbumin

Thrombocytopenia

Risk Factor analysis

Heart Failure St C Fc IV
Hypertension (high blood pr
essure)
Coronary artery disease
Diabetes
Obesity
Hyperthyroidism
Valvular heart disease
Excessive alcohol
consumption
Smoking
Long-term use of anabolic
steroids

PAD
Smoking
Diabetes
Obesity
Hypertension
Dislipidemi
Age
Family history of heart
disease
High level of homocysteine

Management analysis
Emergency: Urgency:

O2 4 L/m NS
Fluid balance (-) 500cc/day
Semifowler position
Diet of heart 1800kcal/day
Inj Furosemide 40mg-40mg-0 IV
Po:
Captopril 3x6,25mg
Inserting NGT
GC/8 hours, if once (-) fluid diet 6x200cc
Omeprazole 1x40mg IV

Non Urgency:

Inj. Ceftriaxone 2x1 gr iv

Stop ASA

Thank you

CONDITION THIS MORNING

Cc:
GCS:
BP:
PR:
RR:
Tax:

PROGRESS NOTE
WAKTU

GCS

TENSI

NADI

GDA

THERAPY

Burch & Wartofsky Criteria for

Thyroid
CRITERIA
VALU SCOStorm
CRITERIA
VALU SCORE
E

RE

Thermoregulatory Dysfunction

CV Dysfunction

37,2 37,7 oC

99 109 bpm

37,8 38,3 oC

10

110 119 bpm

10

38,4 38,8 oC

15

120 129 bpm

15

38,9 39,4 oC

20

130 139 bpm

20

39,5 39,9 oC

25

140 bpm

25

40 oC

30

CHF

CNS Effects
Mild

(agitation)

Mild
10

(pedal edema)

Moderate

(bi-basilar

5
10

rhales)

Moderate

(delirium, psychosis,
extreme lethargy)

Severe

(seizure, coma)

GIH Dysfunction
< 25 : unlikely
25 44: support the diagnosis
45 : highly suggestive of thyroid storm

20

Severe

(pulmonary

15

edema)

30

AF

10

Precipitant
History

Negative
0
Positive
10