MR 6 Maret 10

MORNING REPORT
Saturday, March 6
th
2010
Physician in charge:
IA : dr Heri, dr Endah, dr Satrio, dr Nani
IB : dr.Hanik, dr Frenita
II : dr.ariful
III : dr. C. Singgih W, SpPD

CONSULTATION
1. Mrs. Siti suhariyati/51 y.o/w 20.
Consultation to total parenteral nutrition
Anamnesis:
Patient compalin about mass on her left neck since 5 months before admission, and getting
bigger. He also got difficulty opening her mouth since 3 months before admission, so she just
ate soft food, and sometime fluid diet. Since 2 months before admission, she only could eat
fluid diet, about 3-5 spoons perday or drunk a little water.
She got decreased of body weight (getting thin) since 4 months before admission.passing
stool and passing urine was normal.
Physical examination:
BP: 140/80 mmHg; PR: 84 bpm, reguler; RR: 20 x/mnt; Tax: 36,5
0
C . GCS: 4,5,6.
General appearance: looked severely ill, Underweight, Body weight:35kg, Height:151cm
R/Head & Neck: an (-), ict (-), JVP R+2cmH20, trismus (+)
Mass at R colli S 15x10x10cm
R/Thorax: Heart : ictus invisible, palpable at ICS V MCL S
LHM as ictus, RHM at SL D
S1, S2 single, mur-mur (-)
Lung : Simetris, S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
R/abdomen: convex, soefl, BS (+) N, met (-), undulasion (-)
Liver: unpalpable, liver span 10 cm
Spleen: unpalpable, troubes space tympani
R/ extremity: ed (-)
Laboratory Finding:
Lab Value Lab Value
Leukocyte 13,100 3500-
10000/L
SGOT 25 11-41 U/L
Haemoglobin 14 11,0-16,5g/dl SGPT 17 10-41 U/L
PCV 44.1 35-50% Na 135 136-145
mmol/l
Trombocyte 580,000 150000-
390000/L
K 4.42 3.5-5.0 mmol/l
Albumin 2.89 Cl 103 98-106 mmol/l

ECG:
Sinus Rhytm, HR: 86x/mnt
Frontal Axis: N Horisontal axis: clock wise rotation
PR int: 0.04
QRS compl: 0.04:
QT int: 0.36
T inverted at V1-V2
Conclusion: ischemia anterior

Conclusion:
1. Ca colli Sinistra suscp.ca nasopharing
2. Hypoalbuminemia
2.1 low intake
2.2 Hypercatabolic state
3. Underweight
4. HT st I
4.1 atherosclerosis
4.2 primary HT
Suggestion:
patient could be give total parenteral nutrition via vena central use: Triparen 2: 1 liter/day
lisinopril 1x5 mg/day
Joint care with nefrology department
2. Mrs.Sulastri/65 y.o/W26
Consultation to know cardiology status
Anannesis:
Decreased of consciousness since 3 hours before admission, suddently onset
Cough sometime with yellowish sputum since 1 week before admission
History of hypertension since 8 months before admission (180/......)did not routinelly
controlled, no history of DM
0
C . GCS: 2,2,5.
General appearance: looked severely ill.
R/Head & Neck: an (-), ict (-), JVP R+2cmH20, pupil isocor 3mm
R/Thorax: Heart : ictus invisible, palpable at ICS V MCL S 2 cm lateral
S S V V - - - -
S S V V + - - -
R/abdomen: convex, soefl, BS (+) N, met (-), undulasion (-)
Laboratory Finding:
Lab Value Lab Value
10000/L
SGOT 181 11-41 U/L
Haemoglobin 13.1 11,0-16,5g/dl SGPT 47 10-41 U/L
PCV 37.5 35-50% ureum 37.3 mmol/l
Trombocyte 295,000 150000-
390000/L
creatinin 0.54 mmol/l
RBS 91

ECG:
Frontal Axis: N Horisontal axis: normal
PR int: 0.16
QRS compl: 0.04:
QT int: 0.36
Conclusion: Synus tachicardia

Conclusion:
1. DOC + CVA ICH
2. HF st C fc III
3. Leucositosis
4. HT st II
4.1 atherosclerosis
4.2 primary HT
5. Transaminitis
5.1 Reactif due to no 1
5.2 Liver disease
6. Lung infection
6.1 Pneumonia

Goldman cardiac risk index class II with severe complication risk 5% and cardiovascular
mortality rate 2%.
Suggestion:
O2 8-10 lpm via nrbm
Furosemid inj 40mg-0-0 i.v
Curcuma 3x1 tab
Heart diet I 1500 kcal/day
Joint care with cardiology department.

3. Mrs.Supartini/86 y.o/W24A
Consultation to give tranfusion and GEA
Anannesis:
Generalized weakness since 1 week before admission, and getting worse.
Bleeding pervaginam since 6 months before admission.
Diarrhea since 1 day before admission, 2x, no mucus, no blood, no fever.
Cough since 5 years before admission, sometime with whitish sputum. No history of
shortness of breath, History of hypertension since more than 10 years ago, routinelly took
medication, but patient didnt know the name of medication.no history of DM.
0
C . GCS: 4,5,6
General appearance: looked moderately ill.
R/Head & Neck: an (+), ict (-), JVP R+2cmH20,
R/Thorax: Heart : ictus invisible, palpable at ICS V MCL S 2 cm lateral
S1, S2 single, mur-mur (+) sistolic blowing gr II/6 with punctum maximum at
ictus, radiated to the axilla
S S V V - - - -
S S V V - - - -
R/abdomen: convex, soefl, BS (+) N, met (-),
Laboratory Finding:
Lab Value Lab Value
10000/L
SGOT 18 11-41 U/L
PCV 15.2 35-50% ureum 35.3 10-50 mg/dl
Trombocyte 314,000 150000-
390000/L
creatinin 1.06 0.7-1.5mg/dl
mg/dl
RBS 152 <200mg/dl MCH 31.9 26.5-33.5pq
MCV 88 80-97m
3

ECG:
PR int: 0.20
QRS compl: 0.04:
QT int: 0.36
Conclusion: Synus tachicardia

Conclusion:
1. Menometrorrhagi suscp. Ca cervix
2. Anemia normochrom normocyter
3. GEA + moderate dehidration
4. HF st B
4.1 Anemia heart disease
4.2 HHD
4.3 ASHD
5. Hypoalbuminemia
5.2 Low intake

Suggestion:
PDx: Feces examination, culture, blood smear, reticulosit count, electrolit serum, lipid profile
PTX: O2 2-4 lpm via nc
IVFD NS 0.9% 20dpm
Furosemid inj 20mg-0-0 i.v (after dehidration better)
Inj. Ranitidin 2x50mg iv
Inj. Metochlopramid 3x 10 mg iv
Inf. Ciprofloxacin 2x200mg iv
Diet 1900 kcal/day, low salt, low fat, and low fiber
PRC tranfusion 1 pack/day until HB>10g/dl
Attapulgit 2 tab/diarrhea
Joint care with tropic infection dept.

4. Mrs.Dinasti/20 y.o/W.ICU
Consultation because of anemia(to give tranfusion), transaminitis
Anannesis:
First pregnancy and post sectio cessarea 14 days ago, and transabdominal histerectomy 3
days ago. History of shortness of breath in her up 6 months pregnancy sometime.No
fever.history of Ht(-), shortness of breath before pregnancy (-), DM (-)
BP: 120/70 mmHg; PR: 120 bpm, reguler; RR: on ventilator; Tax: 37.3
0
C . GCS: 4,x,6
General appearance: looked severely ill.
R/Head & Neck: an (+), ict (-), JVP R+2cmH20,
R/Thorax: Heart : ictus invisible, palpable at ICS V MCL S
S S V V - - - -
S S V V - - - -
Laboratory Finding:
Lab Value Lab Value
10000/L
SGOT 210 11-41 U/L
PCV 25.3 35-50% ureum 34.2 10-50 mg/dl
Trombocyte 142,000 150000-
390000/L
creatinin 0.95 0.7-1.5mg/dl
mg/dl
RBS 113 <200mg/dl MCH 31.1 26.5-33.5pq
MCV 88 80-97m
3

ECG:
PR int: 0.08
QRS compl: 0.04:
QT int: 0.32
T inverted at V1-V6
Conclusion: ischemia anterior ekstensif

Conclusion:
1. P1000Ab000 post SC day 14, and TAH day 3 w.i late HPP +Sepsis
2. Anemia normochrom normocyter
2.1 due to no 1
3. Hypoalbuminemia
3.2 Low intake
4. Hypokalemia
4.1 low intake
5. Transaminitis
5.1 reactive hepatitis
5.2 acute hepatitis infection

Goldman cardiac risk index class II with severe complication risk 5% and cardiovascular
mortality rate 2%.
Suggestion:
PDx: Urinalisis, blood culture, urin culture, HBs Ag, Anti HCV, IgG and IgM anti HAV
PTX:
IVFD NS 0.9% 20 dpm
Inj. Ceftriaxon 2x1gr iv
Inf metronidazole 3x500 mg iv
PRC tranfusion 2 pack/day until HB.10 gr/dl
KSR 1x1 tab
Curcuma 3x1 tab
Other treatment as obgyn and anesthesi dept.
Joint care with tropic infection dept.

NEW IN PATIENT

1. Mr. /57y.o/w. Cvcu
Anamnesis:
Chief complaint: chest pain
Patient suffered from chest pain since 3.5 hours before admission, pain at his left chest,
radiated to the back, left arm and jaw, heavy sensation. He also felt shortness of breath. Patient
often got shortness of breath before since 4 years before admission, especially when he walked
about 10 meters, he often woke up at night because of shortness of breath. He also suffered
from leg swelling sometime since 4 years before admission. He had history of HT since 4 years
ago, didnt routinely controlled. He also suffered from nausea, and vomiting since 3 hours
before admission. History of smoking 5 bars/day
BP: 99/67 mmHg; PR: 72 bpm, reguler; RR: 24 x/mnt;
General appearance: looked severely ill, GCS: 4,5,6
R/Head & Neck: an (-), ict (-), JVP R+2cmH20
R/Thorax: Heart : ictus invisible, palpable at ICS VI 2 cm lateral MCL S

S S V V - - - -
S S V V - - - -


Laboratory Finding:
Lab Value Lab Value
Leukocyte 7,600 3500-10000/L SGOT 20 11-41 U/L
MCV 88 80-97H um3 Na 140 136-145 mmol/l
MCH 28.7 26,5-33,5H pg K 3.9 3.5-5.0 mmol/l
PCV 33.9 35-50% Cl 109 98-106 mmol/l
Trombocyte 190,000 150000-390000/L CPK : 86 U/L
CKMB : 38 U/L
Troponin I : (-) 0.04
RBS 180 (<200)mg/dL
Ureum 47.4 10-50g/dL
Creatinine

1.42

0,7-1,5mg/dl

ECG: Synus rhytm, HR 74x/mnt
Frontal axis: N, Horisontal axis: Normal
PR interval: 0,12
QRS comp: 0,08
ST elevation at lead II,III,AVF, V1-V6
RBBB incomplete
Conclusion: IMA anterior ekstensif, RBBB incomplete
Chest X ray: thorax AP, Kv enough, asimetris, soft tissue N, bone N, hemidiaphragma D/S
domeshape, costophrenico angel D sharp, S covered by radiopaque appearance, BVP normal, pulmo:
infiltrat (-), Cor CTR 65%.
Conclusion : looked cardiomegaly
Cue & Clue Problem list Initial dx Planning Dx Planning Tx Plannin
g Mo
Male,57y.o
Typical
1. ACS 1.1 IMA
anterior
extensif
O2 8-10 lpm
(NRBM)
ECG,
cardiac
enzime

chest pain
ECG: ST
elevation at
V1-V6,
II,III,AVF
BP: 90/70
and
inferior
Killip class
IV
Bedrest,
semifowler
position
IVFD NS 0.9%
lifeline
Streptokinase 1.5
million unit in
100cc D5% (drip
in 1 hour)
Inj. LMWh 2x0.6
cc s.c (8 hours after
streptokinase)
Clopidogrel 300mg
continue with
1x75mg
Inj. Pethidin 2.5
mg iv
Diazepam 3x5mg
Simvastatin 0-
20mg
Laxadin 3xCI
Fasting 8 hours,
and continue with
diet heart diet 1200
kcal/day, low salt
Male, 57 y.o
Shortness of
breath
Dispneu de
effort
Paroxismal
nocturnal
dispneu
RR 22 x/mnt
History
Hipertension
cardiomegal
y

2. HF st B
fc IV
2.1 ASHD
2.2 HHD
Lipid profile
echocardiog
raphy
as above

VS
Male, 57 y.o
Nausea
vomiting
3. dispepsia
syndrome
3.1 due to no 1 Inj. Ranitidin
2x50mg iv
Inj.metochloprami
d 3x10mg iv

compla
int

MR 6 Maret 10

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

MR 6 Maret 10

Hochgeladen von

Copyright:

Verfügbare Formate

MORNING REPORT

Das könnte Ihnen auch gefallen