anton ny suwatikr26.docx

8/13/2019 Anton NY suwatikr26.docx

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1

Morning Report

Sunday, 13thOctober 2013

-

Physician In Charge:

IA : dr. Anton, dr. Hesti , dr David (kardio)

IB : dr. Zoraida, dr. Daru

II : dr. Nicholas

III : dr. Bogi Pratomo, Sp.PD-KGEH

Summary Of Database:

Female/71 yo /W 26/Askes

History of present Illness

Chief complain: decreased of conciousness

She suffered from decreased of consciousness since 1 day before admission, gradually onset, the first sign was

vomiting-restless-slurs speech and then deep sleep. The vomiting was transparent brown, about 3-4 glass each,

without blood. After that She become restless, slurs speech and then sleep which cannot be awakening. Their

family called for doctor and Then doctor said She should be brought to RSSA immediately.

Previously patient had been hospitalized at Pavillion RSSA for 14 days, she had cared by four specialist:

cardiologist, neurologist, internist and also medical Rehabilitation. She had been discharge 2 days ago.

History of past illness:

He suffered from colon tumor and had been tumor resection 10thyears ago.

She was admitted in RSSA this March 2013 because of Shortness of breath and leg swelling.

She had Hypertension known since march 2013. History of diabetes and allergic unremarkable.

Family history:

Her mother and sister was diabetes .

She is a pensioners. She had 4 children, one of her son was die because of motor accident.

Reviem of systems

Unremarkable


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2

Physical Examination

BP= 90/palpation

mmHg

PR= 90 bpm irregular RR =10 tpm on NRBM

12 Lpm saturation

95%

Ax. Temp.= 36.30C

General App.: looked severely ill GCS : 1 1 1

Head Anemic conjunctiva (-) Icteric sclerae (-) Pupil isokor D/S 2 mm

Neck stiffness (-)

Neck JVP : R + 0 cm H2O; 300,

Thorax Cor Ictus invisible, palpable at ICS VI, MCL S

RHM SL D

LHM ictus

S1, S2 single, murmur -

Pulmo Symmetric; SF D=S; S| S V | V Rh +|+ Wh - | -S| S V | V +|+ -| -

S| S V |V +|+ - | -

Abdomen soefl, BS (decreased), Liver span 8 cm, traubes space dull ,

Extremities

Urine production

Oedem-, cold acral,

--

LABORATORY FINDINGS

LAB RESULT NORMAL VALUE LAB RESULT NORMAL VALUE

Leukocyte 18.890 3,500-10,000/L Sodium 141 136-145 mmol/l

Hemoglobine 14,4 11.0-16.5 g/dl Potassium 5,34 3.5-5.0 mmol/L

MCV

MCH

77,7

26,6

80-97 m3

26.5-33.5 m3

Chloride 109 98-106 mmol/L

PCV 42,10 35-50% Troponin I


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3

lactate 2,8 3,4 0,6-2,2 mmol/L creatinin 5,44


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Conclusion : cardiomegaly

ECG at RSSA:Irregularly irregular rhytm, HR 50150 bpm, mean HR 100 bpm

No P waveQRS : 0,08 s

QT interval : 0,28 s

FA : cannot be evaluate

HA : normal

Q wave at V1-V2, Strain pattern at II, AVF, V4, V5, V6

Conclusion : atrial Fibrillation NVR + OMI anterior + LVH

Clue and cueProblem

listInitial Dx

Planning

Diagnosis Therapy Monitoring edukasi

Female, 71yoDecrease ofconciousnessGCS 111BP 90/-mmHg

HR: 90bpmCold acral

Anuria

1. Shockcondition

1.1Septiccondition1.2cardiogenic

Serial ECGCardiacmarker/6 hr

O2 jacksen rees 12Lpm

Liquid Diet 1500Kcal/day--NGT

NE 0,05-2mcg/KgBW/Minutes

Dobutamin 5-20mcg/kgbw/min

Ranitidine 2x50 mgIV

SVS every 15UrineproductionSE every 4 hrBGA every 6

hr

Explainedrecentcondition,probable causesof disease,

Female 71 yoDecrease ofconciousnessGCS 111

History of

CVA few

month ago

Head Ctscan

ICH

Ureum 174Creatinin 5.4

2. decreasedofconciousness

2.1Dt No 12.2CVA2.3Uremic

encephalopathy

Treat underlyingdisease

Consult toneurologist

GCS Explainedrecentcondition,probable causesof disease,

Female 71 yoDecrease ofconciousnessGCS 111RR 10tpm12lpm with

jacksen reese

Ureum 174

Creatinin 5.4

Leucocyte

3. Septiccondition

3.1Pneumonia3.2UTI Blood cultureand sensitivity Inj Ciprofloxacin2x400 mg IV

Inj. Ceftriaxon 2x1 gIV

S, VS Explainedrecentcondition,probable causesof disease,


5/5

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18.890

CXR:

pneumonia

Female 71 yo

Ureum 174

Creatinin 5.4BUN/Cr: 14.9

CG-GFR:

7.5ml/min

4. Azotemia renal

4.1 Dt No 14.2CKD USG abdomenif possible Treat underlyingdisease Vs, Explainedrecent

condition,probable causes

of disease,

Female 71 yoBP 90/-ECG: AF

NVR+OMI

anterior +

LVH

Echocardiography HHD

and

ischemic

heart

disease

5. HF st CFC IV

5.1CAD5.2HHD NT proBNP NE 0,05-2mcg/KgBW/Minutes

Dobutamin 5-

20mcg/kgbw/minAs treat above

S, VSECG

Explainedrecentcondition,probable causes

of disease,

Female 71 yoSufferedAlbumin:2,88

6. Hypoalbuminemia

6.1Low intake6.2Hypercatabol

ik state6.3Renal loss

- Treat underlyingdisease

albumin Explainedrecentcondition,probable causes

of disease,Female 71 yo

Shockcondition

ECGatrial

Fibrillation

NVR + OMI

anterior +

LVH

7. AFNVR

7.1Dt. No 17.2OMI anterior7.3HF st C fc4

- Treat underlying

disease

S, VS

ECGmonitoring

Explained

recentcondition,

probable causesof disease

anton ny suwatikr26.docx

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