MORNING REPORT

Monday Maret 6th 2017

Coass in charge:
Amanda Dinar
Consultant on duty : dr. Atma, Sp.PD
 Summary of Data Base
Mr W / 51 years old/W. 26

CHIEF COMPLAINT : decrease of consciouness

ANAMNESE : Hetero anamnesesa
HISTORY OF PRESENT ILLNESS :
Patients complain of decrease of consciouness since two days before
admission. Decrease of consciounesss happens gradually. Seizure (-).
Patient also complained about with nausea but no vomiting. The onset was
concomitant with the onset of decrease of consciouness. This nausea made patients
appetite decrease . His family said that the patient looks thinner than before
Patients also complain of shortness of breath for 2 days. Shortness of breath
happened all day long, and not relieved by rest. Urine output was normal, patient
changing diapers 5 times a day
Patient denied that he has hypertension or diabetes mellitus
 History of Past Ilness: Eighteen days ago, patient was
diagnosed stroke by doctor, patient unable to talk
since that
Family history : DM (-), hypertension (-)
History of medication : patient was not consuming
any drug before admitted to RSSA
Social history: no history of alcohol consumption, no
history of smoking
 Physical examination
General appearance looked severely ill GCS 426
BP : 110/80 PR: 150 bpm RR = 24 tpm Tax = 36 C
Head Anemic conjungtiva (-) Sclera icteric (-), meningeal sign (-)
Neck JVP R + 0 cm H20 30
Thorax: Invisible and palpable at ICS V MCL S
Cor: RHM SL sinistra
LHM ictus
S1, S2 single with no murmur
Lung: Symmetric, SF D = S v v Rh - - Wh - -
v v - - --
v v - - --
Abdomen soefle, BS (+) normal, liver span 8 cm, traubes space tympani, shifting dullness
(-), murphys sign (-)
Extremities Warm, edema -/- MMT 2/5
-/- 2/5
 LABORATORY RESULTS
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 15,00 13,4 17,7 g/dL Natrium 136 136 145 mmol/L
Leucocyte 18030 4.300-10.300/L Kalium 5.19 3,5 5,0 mmol/L
Hematocrit 45,40 40 47 % Chloride 114 98 106 mmol/L
Thrombocyte 382000 142.000- Lactat Acid 2,0 Darah vena : 0,5-
424.000/L 2,2 mmol/L
Darah arteri: 0,5-
1,6 mmol/L
MCV 82,70 80 93 fL Ureum 214,50 16,6 48,5 mg/dL

MCH 27,30 27 31 pg Creatinine 2,84 < 1,2 mg/dL

Differential count 0.2/0.2/85 0-4/0-1/51- Albumin 1,892.12 3.5 5.5 g/dL
.4/8.85,4 67/25-33/2-5 % Bilirubin Total 17,02 < 1,0 mg/dL

SGOT 103 0-40 U/L Direct 14,79 < 0,25 mg/dL

SGPT 192 0-41 U/L Indirect 2,23 < 0,75mg/dL
PPT 12,70 11,1-11,6 APTT 26,30 28,9-30,6
INR 1,22
 URINALYSIS

Lab Value Lab Value

Clear 10 x
Color Yellow Yellow Epitel 3,9 1lpf
pH 6.0 4,5 - 8,0 Cilinder Negatif Lpf

BJ 1.025 1,010 1,015 Hialin - 2

Glucose Negatif Negative Granular - Negative
Protein 2+ Negative 40 x

Keton Negatif Negative Erythrocyte 4,0 3 hpf

Bilirubin Negatif Negative Dysmorfic - Hpf

Urobilinogen 1+ Negative Eumorfic - Hpf

Nitrit Negatif Negative Leucocyte 2189,0 5 hpf
Leucocyte 3+ Negative Cristal - hpf
Blood 3+ Negative Bacteria 8546,3 x 103 23 x 103/mL
 BLOOD GAS ANALYSIS
BGA Value Normal Value
With 02 4 lpm supplementation
PH 7.41 7,35-7,45
PCO2 21,6 35-45 mmHg
PO2 168,1 80-100 mmHg
HCO3 13,7 21-28 mmol/L
Base Excess -11,2 -3 until +3 mmol/L
O2 saturation 99,1 > 95%
Lactic acid 14,8
Conclussion acidosis metabolic fully compesanted with
Alkalosis respiratoric
CXR
ECG (27/9/2015)
 CUE AND CLUE Problem Initial Diagnosis Planning Planning Planning
List Diagnosis Therapy Monitoring
Male / 51 yo 1.AMS 1.1 Uremic Ca, O2 2-4 lpm Subjective
AX : Encephalopathy phosphor Bed rest GCS
patients complain of decrease of
1.2 Septic Head Ct VS
consciouness since two days
encephalopathy Scan
PE: 1.3 CVA second IV: PEdu:
GCS 426 attack Ciprofloxacin Disease
Tax = 36 C 2x200mg Underlying disease
Ceftriaxone 2x1 Treatment Prognosis
LAB :
gr
WBC : 18.360
OT/PT 103
/192 HD Cito
Ur/Cr 214,50
/2,84
Lactic acid: 2,0
 CUE AND CLUE Problem Initial Diagnosis Planning Planning Planning
List Diagnosis Therapy Monitoring
Male / 51 yo 2.Septic 2.1. Urosepsis Subjective
AX : patients complain of decrease Condition IV: VS
of consciouness since two days
Ciprofloxacin
2x200mg PEdu:
PE: Ceftriaxone 2x1 gr Disease
GCS 426 Underlying
PR: 150 bpm disease
Tax = 36 C Treatment
LAB :
Prognosis
WBC : 18.360
Neu 85.4
Urinaysis : bacteria 8546,3 x 103
 CUE AND CLUE Problem Initial Diagnosis Planning Planning Planning
List Diagnosis Therapy Monitoring
Male / 51 yo 3. Urosepsis Urine O2 2-4 lpm Subjective
AX : Culture Bed rest VS
Lo
Antibiotic
PE:
GCS 426 sensitivity IV: PEdu:
PR: 150 bpm Ciprofloxacin Disease
Tax = 36 C 2x200mg Underlying
LAB : Ceftriaxone 2x1 gr disease
WBC : 18.360 Treatment
Neu 85.4
Prognosis
Urinaysis : bacteria 8546,3 x 103
CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy Monitoring
Male / 51 yo 4. Azotemia 4.1 Aki st 2 USG Abdomen Treat Subjective
Ax :
decreased
Prerenal dt sepsis underlying Vital Sign
appetite 4.2 volume disease Ureum
nausea depletion Creatinine
PE : Urine output
N: 150x
LAB :
Ur/Cr 214,50 PEdu:
/2,84 Disease
BUN/Cr: 54,3
Underlying
disease
Treatment
Prognosis
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring

Male / 51 yo 5. 5.1 urinary loss dt Diet protein 0,8 Subjective

AX : AKI st II gr/kgBW/day Vital Sign.
LF : Hypoalbumine
mia 5.2 Albumin / 3 days
Albumin: 2,12
Hypercatabolic
state
THANK YOU