MORNING REPORT

January 13th, 2019

Co Ass :
Maharani Dwi Utari
Iffa Maulida W.A
Nur Amalia P.
Gea Mulyono R. P.

Consultant on duty : dr. Heri Sutanto, Sp.PD

 Summary of Database
Mr S / 74 yo / Ward 26
Heteroanamnesa with his wife
Chief Complaint:
Decrease of Consciousness
History of Present Illness:
Patient came to Emergency Room of Saiful Anwar Hospital with decrease of
consciousness since 2 days before admission, gradually onset. A week ago appeared weak
but still spoke fluently. Then gradually worsened since yesterday, the patient was unable to
communicate and was difficult to wake up.
Patient had diabetes melitus since 3 years ago after took methyl prednosolon, he got
insulin but since 3 month ago changed to 5mg daily of glibenclamide.
Patient also suffered from pemfigus vulgaris since a 4 years ago with bullae at all of his
body, routinely controlled to dermatologist, got methyl prednisolon and topical antibiotic
(gentamicn or fucidic acid). Because of skin eruption worsen, methyl prednisolon was up
titration at 2 month ago with the last doses 48 mg. Patient also had Decreased of appetite
since a week ago. Usually 3 servings containing 5 tablespoons a day. Currently for 3 days the
patient only ate 2 times contains 2 tablespoons.
 Summary of Database
Past Medical History & Medication:
• He had hospitalized before dt skin erruption
• Methyl prednisolon 48 mg
• Glibenclamide 5mg
Family History:
His sister was diagnosed as Diabetes Melitus
Social History:
Patient married and had 2 children
Review of System:
Seizure (-), severe headache (-), vomiting (-)
 Physical Examination
General appearance Looked severely Ill Sat O2 99% on NRBM 10lpm
GCS 445
BP 140/90 mmHg PR 87 bpm regular strong RR 22 tpm Tax 36.5oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Skin turgor decrease, dry lips
Neck JVP R+2 cmH20, lymphnode colli (-), tenderness (-)
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 Soefl, Bowel Sound (+) N, shifting dullness (-)
Liver & Lien/ unpalpable, liver span 8 cm, Traube’s space tympani

Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralisation (-), warm acral, CRT <2”
5|5
 Laboratory Findings (08/01/2019)

LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 17,44 4.700 – 11.300 /µL Ureum 181,40 20-40 mg/dL

Hemoglobine 14,50 11,4 - 15,1 g/dl Creatinine 1,57 <1,2 mg/dL

PCV 50,20% 38 - 42% BUN-cr ratio 53.8

Thrombocyte 327.000 142.000 – 424.000 /µL albumin 3.28 3.5-4.5

MCV 77,30 80-93 fl eGFR 46ml/min/1.73

MCH 25,40 27-31 pg Lactat acid 3.3 <0.5

Eo/Bas/Neu/ 0,0/0,1/96,6/ 0-4/0-1/51-67/ RBS 717 <200 mg/dl

Limf/Mon 2,2/1,1 25-33/2-5
osmolaritas 321 280-300
SGOT 10 0-40 U/L Anion gap 32

SGPT 33 0-41 U/L

Blood Gas Analysis (13/1/19)

BLOOD GAS ANALYSIS (8 Lpm NRBM)

pH 7.29 7,35 – 7,45

pC02 24.7 35 -45

p02 116.6 80 – 100

HC03 12.1 21 – 28

BE - 14.7 (-3) – (+3)

Saturasi 02 99% > 95

Conclusion : Acidosis Metabolic partially Compensated

 LABORATORY FINDINGS
URINALYSIS
LAB VALUE LAB VALUE
Urinalysis 10 x
pH 5,5 Epithelia 0,4 lpf
SG 1,020 Cylinder - lpf
Glucose +3 Hyaline - lpf
Protein +1 Granular - lpf
Keton + Leukocyte - lpf
Bilirubin - Erythrocyte - lpf
Urobilinogen - 40 x
Nitrite - Erythrocyte (eumorfik 17%, 3.9/hpf
dismorfik 83%)
Leucocyte - Leukocyte 1.3/hpf
Erythrocyte - Crystal Hpf
Bacteria 11.1x103/mL
LABORATORY FINDINGS
MONITORING BLOOD GLUCOSE

HOUR VALUE
18.00 282
19.00 243
20.00 264
21.00 201
22.00 191
Electrocardiography (08/01/2019)
Chest X-Ray (08/01/2019)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. S/ 74 y.o/ ward 26 1. DOC 1.1. KAD Treat KAD as guideline Sofa score
1.2. uremic Give empiric antibiotic Monitoring
Subjective encepalopathy Avoid nephroto RBS/hour
- Decrease of dt UTI SE/4 hours
Consciousness gradually 1.3. delirium in BGA/6
- Diagnosed as DM geriatric hours
- No fever
P.Ed :
Objective In geriatric
GCS 445 so many
TD 140/90 mmhg causes of
Tax 36.5 C delirium
Urine production
800 cc in 8 hour
Laboratory
Wbc 17440/ul
Neutrofil 96.6%
Lactic acid 3.3
RBS : 717 mg/dl
Urinalisis : Keton urin (+),
eumorfik 17%, dismorfik
83%
Ur/cr 181.40/ 1.57
qSOFA 1
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. S/ 74 y.o/ ward 26 2. AKI dd acute 3.1. Resusitation 2000cc in ER Urin
on CKD stage II dehydration with maintanance nacl output,
Subjective 3.2. diabetic 0.9% 20 tpm ur/cr post
- DM since 3 years ago kidney disease Avoid nephrotoxic drug resusitation
- Long term used of 3.3. septic
Steroid condition P.Ed :
Equal fluid
Objective balance
TD 140/90 mmhg
Urine production If renal
800 cc in 8 hour function
don’t
Laboratory improve,
Wbc 17440/ul should
Neutrofil 96.6% check CCT
Lactic acid 3.3 and
RBS : 717 mg/dl abdominal
Ur/cr 181.40/ 1.57 USG
BUN-cr ratio 53.8
eGFR 46
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. S/ 74 y.o/ ward 26 3. Moderate 4.1. decrease Postpone from SE/4hour
hyperkalemia renal hyperkalemia correction eCG/12
Subjective excretion. because of patient still in iv hour
Decrease renal function continoeus insulin hbA1C
Profile lipid
Objective
TD 140/90 mmhg P.Ed :
Urine production Insulin can
800 cc in 8 hour lowering
kalium
Laboratory serum
Kalium 5.95
ECG sinus tachycardia + tall T
V2-V6

Ur/cr 181.40/ 1.57

BUN-cr ratio 53.8
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. S/ 74 y.o/ ward 26 4. DM type 2 After hyperglycemic Crisis FBG/ BG2
normoweight resolved hours PP
Subjective OAD Diet DM 1800 kcal/day hbA1C/3
- Stop to consume of Inj Long Acting Insulin month
glycenclamide subcutan 10 IU
- Consume hight dose Inj rapid acting insulin 6x2 P.Ed :
steroid U Routinely
- Family history Brocca formula for diet control
Blood Sugar
Objective Patient need 1800 k calorie
BMI 18 Consist of:
RBS : 717 mg/dl
Carbohidrate 60% =
1260 kcal ~ 315g
(4 kcalori/gram
carbohidrate)

Protein 20% =
420 kcal ~ 84 g
(5 kcalori/gram protein)

Fat 20% =
420 kcal ~ 46,67g
(9 kcalori/gram fat)

Po. Atorvastatin 0-20 mg

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. S/74 yo/ w.26 6. Geriatric Family Support Subjective
Problem
Subjective (inanition, Good relationship between Family
- DOC immobilisation patient and care giver support
- In geriatric condition infection,
- KAD intelectual Treat commorbidities P.Ed :
- UTI impairtment ) Importance
of family
Objective support
Dry lips and good
comuunica
tion
to improve
patient
condition
 Condition This Morning

• Looked moderately ill

• GCS 456 CM
• BP: 131/ 75 mmHg
• PR: 95 bpm
• RR: 24 tpm
• T.ax: 36.3OC