dr.

Nanda

MORNING REPORT
Date : 25 March, 2021
Physician in charge
I : dr. Nanda, dr. Rama, dr. Adsan
II Consultant : dr.
II HCU : dr.
II COVID : dr.
II UGD : dr., dr.
II UGD INCOVID : dr.
Chief on duty : dr.
Consultant on duty : dr.
Facilitator : dr.
 Summary of Database
Mrs. WS / 67 y.o/w.26
Autoanamnesa/Heteroanamnesa with her family
Chief Complaint: Decrease of consciousness
History of Present Illness:
• She was presented to ER with decrease of consciousness after having OAD since several
hours before admission which had been given by primary physician. Her history of blood
glucose was approximately 200. Now she is fully alert in intensive ward.
• She complained about shortness of breath for the last two days and body’s weakness since
one month ago and she had been hospitalized several months ago because of decrease
potassium level.
• Everyday, she was helped by her family to do her activity such as eating, grooming, and
bathing.
• History of diabetes mellitus was denied
 Summary of Database
Past Medical History:
There is no remarkable past medical history before
Family History:
There is no family history with malignancies nor congenital disease before.
Social History:
Patient lives with her husband. She worked as a cracker factory workers in Singosari, Malang.
She had 3 children, no history of abortus, and the patient was menopausal.
Review of System:
General: fatigue (+) weight loss (+) 3 kg for the last 3 months
Skin: within normal limit
Head and neck: within normal limit
Respiratory: shortness of breath (+)
Gastrointestinal: abdomen felt hard
Extremities: palms looked pale
 Physical Examination
General appearance looked moderately ill Sat O2 98% on NRBM 10 lpm
GCS 456 VAS 0/10
BP 156/82 mmHg PR 89 bpm regular strong RR 15 tpm Tax oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+4 cmH20, Hypopigmented lesion
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -
|- -|-
Dullness| Dullness Decrease| Decrease -
|- - |-
Cardio Ictus invisible, palpable at AAL (S) ICS VI
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-)
5|5
 Laboratory Findings (11/08/2020)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 6230 4.700 – 11.300 /µL Ureum 64.1 20-40 mg/dL

Hemoglobine 7.30 11,4 - 15,1 g/dl Creatinine 1.57 <1,2 mg/dL

PCV 20.20 38 - 42% GFR 4.023 >90 mL/min/1.73

m2
Thrombocyte 256000 142.000 – 424.000 /µL Natrium 131 136-145 mmol/L

MCV 76.50 80-93 fl Kalium 2.39 3,5-5,0 mmol/L

MCH 27.70 27-31 pg Chlorida 101 98-106 mmol/L

Eo/Bas/Neu/ 1.1/0.2/80.7/1 0-4/0-1/51-67/ PPT 10.90 9.3-11.4 detik

Limf/Mon 4.8/3.2 25-33/2-5
APTT 25.40 24.8-34.4
SGOT 17 0-40 U/L INR 1.05 0.8-1.30

SGPT 7 0-41 U/L RBS 82 < 200 mg/dl

Albumin 2,78 3.5-5.5 g/dL Calcium 8,8 7,6-11,0 mg/dL

CRP 10,53 <0,3 Phosfor 4,0 2,7-4,5 mg/dL

Procalsitonin 4,21 <0,5 Uric acid 9,2 3,4-7,0 mg/dL

Total antibody anti Negative

Sars-Cov
 Laboratory Findings (15/12/2020)
LAB VALUE NORMAL LAB VALUE NORMAL
Sat Transferin 27% 16-45% Ureum 13.8 16,6 – 48,5 mg/dL

Fe 56 49-151 ug/dL Creatinine 0.50 <1,2 mg/dL

TIBC 210 250-350 ug/dL SGOT 27 0-32

Thrombocyte 14.000 142.000 – 424.000 /µL SGPT 13 0-33

MCV 67.6 80-93 fl Alb 4.19

MCH 18.7 27-31 pg PPT 11.1 11.1

RDW 25.80 11.5 – 14.5 % INR 1.07 <1.5

Reticulosit absolut 0.2622 x 106 APTT 25.7 25.7

Reticulocyte 7.47% 0,5-2,5 RBS 93 < 200

Reticulocyte index 25.6 28.8-32.9 pg AFP 1.64 < 7.0 ng/mL

IPF 31.7 1.1-6.1 % CA-125 193.8 < 35 U/mL

Total antibody Non reactive Non reactive

SARS COV 2
 Urinalysis (11/08/2020)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity Clear 10 x
Color Yellow Epithelia Negative ≤1
pH 6.0 4.5 – 8.0 Cylinder Negative
SG 1.010 1.005 – 1.030 Hyaline Negative
Glucose Negative negative Granular Negative
Protein 1+ negative Other
Keton negative negative
Bilirubin Negative negative 40 x
Urobilinogen Negative negative Erythrocyte 2.1 ≤3
Nitrite Negative negative Leukocyte 44.5 ≤5
Leukocyte 2+ negative Crystal
Erythrocyte 1+ negative Bacteria 5092300 ≤23 x 103/ml
Other
 Blood Gas Analysis (11/08/2020)

With NRBM 10 lpm Normal

pH 7.43 7.35-7.45
pCO2 47.8 35 – 45 mmHg
pO2 105.2 80 – 100 mmHg
HCO3 31.7 21 – 28 m mol/L
O2 saturation 97.7 > 95 %
BE 7.2 (-3) - (+3) m mol/L
Temperature 36.7
Hb 7.3
Conclusion: primary metabolic alkalosis
 Electrocardiography (11/08/2020)
• Sinus rhythm, HR 73 bpm regular/irregular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0.10”
• QRS complex : 0.08”
• Q wave : no pathological Q
• QT interval : 0.34”
• QT interval corrected : 0.39”
• ST segment : isoelectric
• Others :

Conclusion : Sinus Rhythm 73 bpm

Chest X-Ray (17/08/2020)
 Chest X-Ray (7/12/2020)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S were dome-shaped
• Phrenico-costalis angle D and S were sharp
• Pulmo: bronchovesicular pattern was normal, no
infiltrate/nodule/cavity
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (-)
Conclusion: cor and pulmo within normal limit
BOF (17/08/2020)
 BOF AP (17/08/2020)

 Pre peritoneal fat line D/S : Normal

 Psoas line : Normal
 Hepar Contour/Lien : Enlarged hepar, lien
normal
 Renal Contour D/S : Closed with gas material
 Skeleton : Osteofit in vertebrae
lumbalis.
 Intestinal gas distribution increased with mild dilatation in the
small bowel, diameter 2.6 cm.
 Conclusion: Partial small bowel obstruction DD meteorismus,
hepatomegaly, spondylosis lumbalis
Abdominal USG (04/05/2020)
 Abdominal USG (04/05/2020)
 Hepar : size was enlarged; intensity echo parenchim increased
heterogen, edge was blunt, irregular, there is no dilatation of IHBD.EHBD, v.portal/v.
hepatica normal, multiple nodul lobus right and left hepar with various in size
 Gall bladder : size and shape were normal; no visible stone/mass/sludge; wall
thickening (-)
 Pancreas : size was normal; homogenous parenchym; calcification (-)
 Lien : size was normal; mass (-); cyst (-)
 Renal D/S : size was normal; echo cortex normal; margin of sinus cortex was
definite; ectasis at pelvicocalyceal (-); no visible stone/mass/cyst
 Vesica urinaria : enough content; smooth wall, mass (-), calcification (-)
 Prostat : size was enlarged (Vol=30, 46 ml), echoparenchym normal, no mass nor
calsification
 Extraluminal free fluid in cavum abdomen
Conclusion: Cirrhosis hepatis, cholelithiasis, kista ren dextra and nephrolithiasis,
prostatitis chronic
CT-Scan (08/05/20)
 CT-Scan (08/05/20)
• Hipodense lesion uncertain margin, in nucleus caudatus sinistra,
nucleus lentiformis sinistra, and corona radiata sinsitra
• Hipodens with certain margin, in the sub corteks corteks lobus
frontal dextra
• Sulcii, fissure silvii dilated and gyri prominent
• Differentiation gray and white matter in normal app.
• Ventricel system and cysterna system normal
• Mesencephalon, pons and cerebellium normal
• Sinus paranasalis visualized normal
• Orbita and mastoid bilateral normal
Conclusion: Acute infark in nucleus caudatus sinistra, nucleus
lentiformis sinistra, and corona radiata sinistra
Infark late sub acute in corteks sub korteks lobus frontal dextra
Senile Brain Atrophy
Clinical Feature (30/05/20)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Post 1.1 OAD- - Secure airway RBG/4
Mrs. WS / 67 y.o/w.26
hypoglycaemia Induced - Give IV Bolus D40% 50 hours
Subjective
• Decrease of
with coma cc  IVFD D10% 500
cc/24 hours FBG/2HPPB
consciousness G
• OAD consumption - Free diet 1700 kkal/day
Objective
Education:
• GCS 1-1-1  456 Free diet
Laboratory
• RBG 50  150 mg/dL
 Problem Analysis

Suspicious of
Hyperaldosteronism

Hypertension Hypokalemia Alkalosis

Inanition

Hypomagnes Geriatric
Heart Failure
emia Problems

Immobilizatio
n
Acute Kidney
Weakness
Injury
 Risk Factors Analysis
Problem Theory Patient
Hypoglyca ‐ Advance age
emia State ‐ Concomitant
(OAD use more than
Induced) one drugs
‐ Reduce intake
of
carbohydrate
since 1 week
ago

American Diabetes Association. Standards of medical

care in diabetes—2017
 Key Message Pathophysiology

• Potassium (K+) plays a key role in maintaining

normal cell function.
• K+ is the main intracellular cation and almost all
cells have the pump called ‘Na+-K+-ATPase’, which
pumps sodium (Na+) out of the cell and K+ into the
cell leading to a K+ gradient across the cell
membrane (K+ in > K+ out), which is partially
responsible for maintaining the potential difference
across membrane.
• Many cell functions rely on this potential
difference, particularly in excitable tissues, such as
nerve and muscle.
Kardalas, E., Paschou, S. A., Anagnostis, P., Muscogiuri, G., Siasos, G., & Vryonidou, A. (2018). Hypokalemia: a clinical
update. Endocrine connections, 7(4), R135–R146. https://doi.org/10.1530/EC-18-0109
 Key Message Diagnosis

Kardalas, E., Paschou, S. A., Anagnostis, P., Muscogiuri, G., Siasos, G., & Vryonidou, A. (2018). Hypokalemia: a clinical
update. Endocrine connections, 7(4), R135–R146. https://doi.org/10.1530/EC-18-0109
 Key Message Management

Kardalas, E., Paschou, S. A., Anagnostis, P., Muscogiuri, G., Siasos, G., & Vryonidou, A. (2018). Hypokalemia: a clinical
update. Endocrine connections, 7(4), R135–R146. https://doi.org/10.1530/EC-18-0109
 Key Message Social

• Management of the underlying disease or contributing factors

constitutes the cornerstone of therapeutic approach.
• Potassium should be gradually replaced, preferably by oral
administration if clinically feasible.
• Educate the patient and patient’s family regarding the main
problem (hematemesis melena) and how the cause is still
under diagnostic process.
• Educate the given pharmacologic and non – pharmacologic
treatment in the ward, regarding the purpose and the side –
effects.
• Good emotional support from the family, health care
provider, and spiritual support must be given to the patient
 Condition Patient this Morning:

• GCS : 456
• BP : 136/76 mmHg
• RR : 20 bpm
• Tax : 36,8 C
• SpO2 : 98% on room air
• FBG :-
 Prognosis

• Ad vitam : dubia
• Ad functionam : dubia
• Ad sanationam : dubia