Duty Report

Friday, November 23th 2018

dr. Surya Abadi K

Physician in charge:
IA : dr. Surya, dr. Yosi, dr. Osa (cardio), dr. Dipto
II :,
CVCU : dr. Rokhma
HCU : dr. Ellima
UGD : dr. Roni, dr. Fatoni
Chief On Duty : dr. Fadila
Consultant : dr. Supriono, Sp.PD-KGEH

Summary of Database:
Mrs. Djumiati/ 64 yo/ 11413280/R 25

Chief complaint: Hard to swallowing

Anamnese
Patient came to Emergency Ward Saiful Anwar General Hospital with chief complaint hard to
swallowing since 2 hours before admission. It happened spontaneously when patient ate a piece of Melon.
Now the complaint was subsided by itself.

She had been diagnosed of Cerebrovascular Attack a month ago, and admitted to Kanjuruhan General
Hospital, but didn’t performed CT Scan. She had a left sided weakness, slurred of speech and facial paralysis
because of the CVA. She controlled once in Neurology Outpatient clinic and didn’t know the name of the drug
she consumed.

She had Diabetes Mellitus since 1 year ago. She routinely using insulin this month, with the dosage 16
unit at night, and 16 unit every time she had meal. She had hypertension since 1 year ago, and routinely
consumed drug but didn’t the name of it.

1
Physial Examination
General appearance = looked mildly ill GCS 456
Ward BP =140/80 mmHg PR = 92 bpm, regular, RR = 18 tpm, Tax : 36.5 °C
strong enough SatO2 = 99% on VAS= 0/10
RA BW: 55 kg, Height:
160 cm
BMI: 19.05
Head Pale conjunctiva (-) Icteric sclera (-)
Pupil isokor 3mm/3mm
Neck JVP R+0 cmH2O (30/45degree), lymphnode enlargement (-)
Chest
Heart: Ictus palpable at ICS V MCL S
LHM ≈ ictus // RHM: SL D
S1, S2 single, murmur (-) gallop (-)
Lung: Symmetric, SF D=S,
Percusion: S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen Flat, soefl, bowel sound + N
liver span 10 cm, unpalpable
Traube space timpany
Extremities Warm akral, CRT<2, edema - -
MMT 5/3
5/4
Neurological examination Parese N VII UMN
Parese N XII UMN
Pathological reflex (-/+)

2
Laboratory Findings

Lab Value (Normal) Lab Value (Normal)

Haemoglobine 14,0 4.700 – 11.300/µL Natrium 138 136-145

mmol/L

Leukocyte 9680 11,4 -15,1 g/dl Kalium 3.21 3,5-5,0 mmol/L

Hematocrit 41,2 38 - 42% Chlorida 105 98-106 mmol/L

Trombocyte 253.000 142.000– 424.000 RBS 351 (ER) < 200 mg/dl
/µL 187 (ward)

MCV 82.9 80-93 fl Ureum 24.18 20-40 mg/Dl

MCH 28.60 27-31 pg Creatinine 0.46 <1,2 mg/Dl

Eo/Bas/Neu/limf/ 0.5/0.6/67. 0-4/0-1/51-67/25-

Mon 2/26.2/5.4 33/2-5

SGOT 22 u/L

SGPT 11 u/L

 ECG : sinus rhytm HR 87 bpm + RBBB

3
 CUE AND CLUE PL IDx PDx PTx PMo and
PEdu
Mrs. D/ 63 yo/ ward 25 1. Dysfagia 1.1 CVA Endoscopy Nonpharmacologies S, VS
Anamnesis : (resolved) Sequele -Bedrest
- Hard to swallowing 1.2 Diabetic - Low fat diet P.Edu : Eat
- History of CVA since 1 month ago neuropathy soft food
- History of DM since 1 year ago 1.3 Esophagitis Pharmacologies
- - IVFD NS 1500cc/ 24 hours
- PO UDCA 3x250mg
Physical examination : - PO Curcuma 3x1
Parese N XII UMN

Laboratory :
Mrs. D/ 63 yo/ ward 25 2. DM Type 2 Nonpharmacologies FBG,
Anamnesis : normoweight Diet DM 1700 kcal/day 2hPPBG,
- History of DM since 1 year ago, using insulin on insulin HbA1C
Pharmacologies
- IVFD NS 1500cc/24 hour P.Edu :
Physical examination : - SC Levemir 0-0-10iu Disease,
BW 55 kg (postponed -> waiting for therapy and
Height 160cm HbA1C) prognosis
BMI 19.05

Laboratory :
RBG 351 (ER) -> 187 (Ward)
Mrs. D/ 63 yo/ ward 25 3. HT on Nonpharmacologies Blood preure
Anamnesis : treatment Low sodium diet
- History of HT since 1 year ago, routine took a <2gram/day P.Edu : Eat
drug but didn’t know the name of it less salt
Pharmacologies
PO Captopril 3x25mg
Physical examination : PO Amlodipin 1x10mg
BP 170/100 (ER) -> 140/80 (ward)

4
Laboratory :

Mrs. D/ 63 yo/ ward 25 4. CVA Sequele 4.1 CVA Infarct Nonpharmacologies S, VS,
Anamnesis : 4.2 CVA Consult to Neurology Dept Neurological
- Hard to swallowing Bleeding state
- History of CVA since 1 month ago Pharmacologies
- Left sided weakness P.Edu :
- Slurred of speech + Facial paralysis Rehabilitation
program,
Physical examination :
Parese N XII UMN
Parese N VII UMN
MMT 5/3
5/4
Babinski (-/+)

Laboratory :