MORNING REPORT

DUTY ON JANUARY 8TH 2020

Internal Medicine – Udayana University

Patient Identity
• Name :
• Sex :
• Date of birth :
• Age :
• Address :
• Occupation :
• Education Status :
• Marital Status :
• Religion :
• Nationality/Ethnic :
• Medical Record :
Anamnesis
 Chief Complaint : Vomiting
 Present Illness History :
Patient complaint of vomiting since 1 day before admission. Vomit
consist of food remains and water, approximately 10 times since the first
occurrence. Patient usually vomit after she eat or trying to drink. Patient said
the vomit was so hard that the patient feel discomfort because of burning
sensation around the neck and cannot do activity as usual. Patient denied
any projectile vomiting or bloody vomiting.
Patient also complaint of stomachache since 1 day before admission.
Pain was felt mainly on the upper center region of stomach. The pain appear
each time the patient wants to vomit and worsen each time the patient
vomited. Pain was felt like a prickling sensation. The pain got better if patient
sit, and worsen as she lay down.
Anamnesis
 Present Illness History :
Patient also complaint nausea since 2 days before admission. Nausea
was felt after she prepare for some traditional event. Nausea was felt like her
stomach was full and about to throw up. The complain was so bad that the
patient cannot eat and drink although she want to. Complain gets better
when patient rest.
Patient also felt fatigue and limp since she cannot eat and drink
because of the nausea. Patient feel better when she rest. Patient denied any
complain of fever before. Complain regarding defecation and urination
were also denied.
Anamnesis
 Past Illness History :
Patient was diagnosed with diabetes mellitus type 2 since 4 years ago,
with blood sugar at the time around 300mg/dL from random glucose test at
Sanglah Hospital. Patient was given insulin “lantus” as anti diabetic drug but
stoped by herself. She then has been consuming Metformin 500mg 3 times a
day that were given by a general practitioner when checking her glucose
level. patient didn’t consumed he drug routinely. Patient was told that her
glucose lever was varied between 200-300mg/dL, but didn’t get any
additional drug from the doctor.
Anamnesis
 Family Illness History :
The patient’s father was also diagnosed with Diabetes Mellitus type II.
Any other history of systemic disease in family, such as hypertension, cardiac
disease, kidney disease, or respiratory disease was denied.
 Social and Personal History
Patient worked as a marketer at traditional market near her place.
Patient said she usually consumed snack while waiting for customer when
working, but not so much. Patient denied any history of smoking and alcohol
consumption.
Physical Examination
Vital Sign
• Appearance : Moderately ill
• Consciousness : Compos Mentis, GCS E4 V5 M6
• Blood pressure : 120/60 mmHg
• Pulse rate : 76x/minute
• Respiration rate : 22x/minute
• Tax : 36.2 o C
• VAS : 3/10
• SpO2 : 98% on room air
• Body weight : 43 kg
• Body height : 150 cm
• BMI : 19 (Normal)
Physical Examination
General State
Head : normocephali
Eyes : anemic (-/-), icterus (-/-), pupil reflex (+/+) isokor, sungken
eye (+)
ENT :
Ear : hiperemi (-/-), secret (-/-)
Nose : conca enlargement (-/-), secret (-/-)
Mouth : tonsils T1/T1 hyperemia (-), Dry Mucose (+)
 Neck : lymph node enlargement (-)
 Physical Examination
Thorax : Symetrical
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis ICS VI, anterior axillary line sinistra
Percussion : Right Border : PSL Dextra
Left Border : ICS VI axillary line sinistra
Lower border : ICS VI Sinistra
Auscultation : S1 S2 single, reguler, murmur (-)
 Physical Examination
 Pulmo
Inspection : Symmetric
Palpation : Symmetric, vocal fremitus normal N|N
N|N
N|N
Percussion : Sonor/Sonor
Auscultation : Vesicular +|+ Ronchi -|- Wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
 Physical Examination
 Abdomen
Inspection : Distention (-)
Auscultation : Bowel Sound (+) normal
Palpation : Abdominal pain (-), liver unpalpable, spleen
unpalpable, mass (-)
Percussion : Thympany (+), traube space (+)
Extremity : Warm +|+ Edema -|-
+|+ -|-
CRT < 2 seconds, Wound on plantar (-), Foot sensory
Loss (-), Dorsalis Pedis Artery palpable, stong
Parameter Result Unit Reference
Range
WBC 10,96 103/µL 4.1 - 11.0
Laboratory
NE% 73,94 % 47 - 80
LY% 18,17 % 13 - 40
Examination
Complete Blood Count
MO% 6,94 % 2.0 - 11.0 08/01/2020
EO% 0,05 % 0.0 - 5.0
BA% 0,010 % 0.0 - 2.0
NE# 8,10 103/µL 2.50 - 7.50
LY# 1,99 103/µL 1.00 - 4.00
MO# 0,76 103/µL 0.10 - 1.20
EO# 0,01 103/µL 0.00 - 0.50
BA# 0,10 103/µL 0.0 - 0.1
RBC 4,33 106/µL 4.5 – 5.9
HGB 13,44 g/dL 13.5-17.5
HCT 39,97 % 41.0-53.0
Parameter Result Unit Reference
range
MCV 92,43 fL 80.0 - 100.0
Laboratory
MCH 31,08 pg 26.0 - 34.0 Examination
MCHC 33,62 g/dL 31 - 36 Complete Blood Count
08/01/2020
RDW 12,53 % 11.6 - 14.8
PLT 283,70 103/µL 140 - 440
MPV 8,35 fL 6.80 - 10.0
ALT/SGPT 19,40 U/L 11.00 - 50.00
AST/SGOT 13,3 U/L 11.00 – 27.00
BUN 17,80 mg/dL 8.00 - 23.00
Creatinine 0,55 mg/dL 0.50 - 0.90
e-GFR 105,19 >= 90
Albumin 4,3 g/dL 3,40-4,80
 Laboratory
Examination
Parameter Result Unit Reference range Glucose Profile
08/01/2020

Random 384 mg/dL 70.0 - 140.0

Glucose
HbA1C 12,4 % 4,8- 5,9
Parameter Result Unit Reference
range Laboratory
pH 7,22 7,35 – 7,45 Examination
pCO2 25,7 mmHg 35.00 – 45.00 Blood Gas Analysis
08/01/2020
pO2 65,90 mmHg 80.00 – 100.00
Beecf -17,5 Mmol/L -2 – 2
HCO3- 10,30 Mmol/L 22,00 – 26,00
SO2c 89,5 % 95 – 100
TCO2 11,10 Mmol/L 24.00 – 30,00
Natrium 132 mmol/L 136 – 145
Kalium 4,58 mmol/L 3,50 – 5,10
Cloride 106 mmol/L 96 – 108
Parameter Result Unit Reference
range
pH 5,00 4,5 – 8 Laboratory
Berat Jenis 1.025 1.003 – 1.035 Examination
Leukosit Negatif Leuco/uL Negatif Urine Analysis

Nitrit Negatif mg/dL Negatif 08/01/2020

Protein 25 (+1) mg/dL Negatif

Glucose 1000 (+4) mg/dL Negatif
Keton 150 (+3) mg/dL Negatif
Darah Negatif Ery/uL Negatif
Urobilinogen Normal mg/dL Normal
Bilirubin Negatif mg/dL Negatif
Warna P.Yel P.Yellow –
Yellow
Parameter Result Unit Reference Laboratory
range
Examination
Leukosit 0–1 /LPB >7 Urine Analysis
Sedimen
08/01/2020
Berat Jenis - /LPB >5
Sel Epitel
Sedimen
Gepeng 1–2 /LPB
Silinder Granula + /LPB
Sedimen
Bakteri Pos (+) /Lp
Supporting
Examination
Thorax X-Ray (8/1/2020)
• Aortosclerosis
• Pulmo tak tampak
Kelainan
• Spondulosis Thoracalis
Diagnosis
1. Diabetes Mellitus Type II
• Ketoacidosis Diabeticum
• Gastropathy Diabeticum
Mild-Moderate Dehydration
Planning
Therapy:
• IFVD NACl 0,9% loading 500ml/hour  reevaluate Hydration
Status, if corrected maintenance fluid distribution 20 dpm
• Diabetic Mellitus dietary 1700 kkal every day
• Metoklopramid 10mg IV every 8 hours
• Insulin aspart 4 unit SC every 8 ours (before meal, if can eat ½
portion of the meal
• Insulin glargine 10 unit SC every 24 hour
• Postpone metformin
• Lansoprazole 30mg IV every 24 hour
Planning
Monitoring:
• Vital Sign
• Complains
• Blood Sugar two hours PP
• Fasting Blood sugar
• Fluid Balance
Prognosis
• Ad Vitam : Dubia ad bonam
• Ad Functionam : Dubia ad bonam
• Ad Sanationam : Dubia ad malam
THANK YOU
Any Questiom?