MORNING REPORT

Date : June 17, 2019

Physician in charge
I : dr. Rezdy, dr. Pandu, dr. Zika, dr. Adinda, dr. Novi
II CVCU : dr. Hana, dr. Reizal
II HCU : dr. Arde
II UGD : dr. Dela, dr. Ellisma
Chief on duty : dr. Handy
Consultant on duty : dr. Syifa Mustika, SpPD-KGEH
Facilitator : dr. Laksmi Sasiarini, SpPD-KEMD
 Summary of Database
Mrs. N/36 yo/ward 26
Heteroanamnese with her husband

Chief Complaint:
decrease of consciousness

History of Present Illness:

Decrease of consciousness since 3 hours before the admission (03:30 AM). Previously treated
at a health center for a day. The family said that for 3 days the patients had nausea and
vomiting as much as 3-6 times every day, today she did not vomit at all. Her body feels weak,
the patient has no appetite for 3 days. There is no headache nor half body weakness before.
Cough, fever, tightness were denied. History of DM is denied, patient never check blood
sugar. History of high blood is denied, patient almost never controlled her health. Family
history of DM and HT is unknown.
 Summary of Database
Past Medical History:
-
Family History:
history of DM in her family is unknown

Social History:
she is an entrepreneur

Review of System:
fever (-), cough (-)
 Physical Examination
General appearance look moderately ill Sat O2 99 % on NRBM 10 lpm
GCS 434 VAS 0/10
BP 115/80 mmHg PR 116 bpm regular strong RR 24 tpm Tax 36,1oC
Head Conjuctiva Anemic (-), Sclera Icteric (-),
Neck JVP R+ 3 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-
Sonor | Sonor Vesicular | Vesicular -|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 9 cm, epigastric tenderness (-)
Lien/ Traube space tymphany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization(-)
5|5
 Laboratory Findings (16/6/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 25.200 4.700 – 11.300 /µL Ureum 79,2 20-40 mg/dL

Hemoglobine 13,5 11,4 - 15,1 g/dl Creatinine 1,51 <1,2 mg/dL

PCV 42,4 38 - 42%

Thrombocyte 423.000 142.000 – 424.000 /µL Natrium 137 136-145 mmol/L

MCV 87,6 80-93 fl Kalium 5,74 3,5-5,0 mmol/L

MCH 27,9 27-31 pg Chlorida 108 98-106 mmol/L

Eo/Bas/Neu/ 0/0,4/84,8/6,9 0-4/0-1/51-67/ RBS 335 < 200 mg/dl

Limf/Mon /7,9 25-33/2-5
PPT - 9.3-11.4 seconds
SGOT - 0-40 U/L APTT - 24.8-34.4

SGPT - 0-41 U/L INR - 0.8-1.30

Serum Osm 307 285-295 mOsm/kg Calcium - 7,6-11,0

 Urinalysis (16/6/2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity clear 10 x
Color yellow Epithelia 3,9 ≤1

pH 6,0 4.5 – 8.0 Cylinder -

SG 1,015 1.005 – 1.030 Hyaline -

Glucose 3+ negative Granular

Protein 1+ negative Other -

Keton 2+ negative

Bilirubin - negative 40 x
Urobilinogen 3,2 <17 Erythrocyte 6,8 ≤3
Nitrite - negative Leukocyte 2,3 ≤5
Leukocyte - negative Crystal -
Erythrocyte Bacteria ≤23 x
1+ negative 204,2 x 1000 mL
103/ml
 Blood Gas Analysis (16/6/2019)

With NRBM 10 lpm Normal

pH 6,72 7.35-7.45
pCO2 15,3 35 – 45 mmHg
pO2 166,6 80 – 100 mmHg
HCO3 -34,0 21 – 28 m mol/L
O2 saturation 99,9% > 95 %
BE -34,0 (-3) - (+3) m mol/L
Temperature 37
Hb 9,9
Conclusion: metabolic acidosis partially compensated
Electrocardiography (16/6/2019)
 Electrocardiography (16/6/2019)

• Sinus rhythm, HR 110 bpm

• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : 0,08 s
• PR interval : 0,10 s
• QRS complex : 0,12 s
• ST segment : isoelectric
• QT interval : 0,36 s
• T wave : tall T wave (+)

Conclusion : sinus tachycardia 110 bpm, tall T wave

Chest X-Ray (16/6/2019)
 Chest X-Ray ()

• AP position, symmetric, enough KV, enough inspiration

• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: normal chest x-ray

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. N/36 yo 1. Severe DKA 1.1 LADA - FPG/2hppg - bed rest - RBS/hour
1.2 T2DM - HbA1c - equal fluid balance - SE/4 hrs
Subjective - GAD65 - NRBM 10 lpm - BGA/6 hrs
DOC (+) - IVFD NaCl ,9% 2000 cc/24
Unknown DM hrs
- IV rapid insulin 0,1
Objective IU/kgBW/hour
GCS 233 >> 334 - IV Nabic 100 mEq in 2
kussmaul (+) << hours

Laboratory
RBS: 409 > 513 > 407 > 335
keton 2+
BGA: acidosis metabolic
partially compensated
(pH: 6,7)

Osm: 307 mOsm/kg

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. N/36 yo 2. Moderate 2.1 related to - urine - treat DKA - RFT/3 days
Hyperkalemia DKA potassium - ECG serial/24 hrs
Subjective 2.1.1 Insulin
weakness (+) deficiency
2.2 Decrease
Objective of renal
GCS 334 excretion

Laboratory
Potassium: 5,74

ECG (16/6/19): Tall T wave

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. N/36 yo 3. Leucocytosis 3.1 Reactive dt no. 1 - urine culture - confirm diagnosis - CBC serial
3.2 Infection (?)
Subjective 3.2.1 UTI
-

Objective
-

Laboratory
UL: bacteria
204,2x1000/ml
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. N/36 yo 4. AKI stage 1 4.1 related to - - IVFD NaCl 0,9% 6 litres in Ureum,
no. 1 24 hours creatinine
Subjective 4.1.1 volume - treat underlying diease serial, urine
Urination (+) depletion production
4.1.2 severe
Objective acidosis
Urine production: 1000
cc/16 hours

Laboratory
Ureum: 79,2
Creatinine: 1,51
 Problem Analysis

LADA DM type 2

Insulin deficiency

Diabetic
Ketoacidosis

Insulin deficiency acute stress

Hyperkalemia volume depletion Leucocytosis

<< renal excretion

Acute Kidney
Injury
Risk Factors Analysis
Key Message Management
Key Message Diagnosis
 Condition This Morning

• GCS : 335
• BP : 110/70 mmHg
• HR : 108 bpm
• RR : 22 tpm
• tax : 35,8 C
• SpO2 : 98% NRBM 8 lpm
• RBS : 178 mg/dl