Morning Report

Friday, May 27th 2016

CO ASSISTANCE INCHARGE

FADILLA SAFIRA
NENENG WULANDARI

MODERATOR :
dr. IQBAL LAHMADI Sp.PD
 Total Patients

Total patients :
Melati ward : 6 patients

Kenanga ward : 14 patients

Total Patients in ward:

Melati ward : 1 patients
Female, 74 y.o., Dx : Dyspepsia syndrome, CHF stage B FC II
Female, 49 y.o., Dx : dyspepsia syndrome, HT stage I
Female 17 y.o., Dx : mildly anemia

Kenanga ward : 1 patients

Male, 73 y.o., Dx: dyspepsia syndrome + acute watery diarrhea
 Summary of Database

Mr. M/Male /60 y.o

Chief complaint : Shortness of breath

Patient suffered from shortness of breath since 2 weeks

ago which was getting worse by recumbent position and
relieved by sitting position. Patient said that he was
oftenly awake in the night because of cough and
shortness of breath. Patient complained that since 1
month ago he easily felt fatigue when walking in short
disatnce. He complained cough since 1 year ago, it was
followed by whitish sputum with no blood in sputum.
 Patient said that since 2 weeks ago, he is getting
skinny, and loss of his appetitte.
Patient was a active smoker, he smoked 1 pack (20
cigarettes)/ day since 45 years ago.
Patient also complained epigastric pain which is felt
since 2 weeks ago. He felt it like being stabbed
continuously, and getting worse when he had late
lunch or late dinner. He admitted that he oftenly
consume traditional herbal medicine to relieved his
fatigue. Nausea (+), vomitting 2 times.
 Past Medical History

Patient had been hospitalized with diagnosis

bronchopneumonia, and COPD 1 years ago
 Physical examination in Kenanga Ward
BP = 110/70mmHg PR : 96 tpm, regular, RR = 24 tpm, T ax 36,8oC

General appearance looked mildly ill GCS 456

Head Anemic + Icteric -

Neck JVP 5 cmH2O

Thorax Invisible Palpable at Ictus ICS VI MCL S,

Heart RHM SL D, LHM as ictus,
S1 S2 single, mur mur (-), gallop (-)

lung Simetric, SF D = S SS v v Rh - - Wh - -
SS bv bv + + - -
DS bv bv + + - -

Abdomen Convex, Soefl, Hepar : Liver span 12 cm, tenderness in epigastric region

Extremities Oedema in both lower extremity -/-

ECG in ER
 Interpretation

Sinus Rhythm, HR 107 tpm

Axis :
Frontal axis : normal axis
Horizontal axis : counter clock wise (V2-V3)
PR interval : 0,20 ms
QRS complex : 0,10 ms
QT interval : 0,40 ms

Conclusion : Sinus Tachycardia with HR 107 tpm

CXR
 Interpretation

AP position, symmetric
Soft tissue and bone normal
Trachea in the middle
ICS D/S wide
Left and right costophrenicocostalis angle are sharp
Hemithorax : hyperaeration
Heart : site normal, Size<55%, tear drop shape
Lung : Bronchovascular pattern increase in both lungs

Concl: emphysematous lung with suggested secondary

infection e.c. bronchopneumonia dd/ pulmonary TB
 Lab Value Lab Value

Leukocyte 12600 3500;10000/L Ureum 25 10-50mg/dL

Haemoglobin 10,9 11,0-16,5g/dl Creatinine 1.0 0,7-1,5mg/dL

MCV 75,1 80-97 SGOT 93 11-41U/L

MCH 26,3 26,5-33,5 SGPT 88 10-41U/L

Thrombocyte 220.000 150000-

390000/L
RBS 104 (<200)mg/dL

ESR 25 mm/ 0-10 mm/hour

hour
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING THERAPY PLANNING
LIST DIAGNOSE DIAGNOSE MONITORI
NG

male/60 yo 1. SOB 1.1. Chronic Spirometr Smoking cessation VS

Ax: lung disease y Venflon Complain
SOB, PND (+), DOE with Sputum Free diet
(+), Orthopnea(+), O2 1 lpm titrate every
secondary acid fast 15 minute until SpO2
cough with whitish
sputum since 1 years
infection staining 88-92% via cannule
ago, decresed of body 1.1.1 COPD nasal
Weight (+), decreased with Exacerbation :
of appetitte, Pneumonia nebulization
1.1.2. Salbutamol 2,5 mg, if
PE: Tuberculosis no response repeat
Lung : ves (+/+), Rh nebulization with
1.1.3 SOPT Ipratropium Br +
(+/+), Wh (-/-)
albuterol
CXR : emphysematous Prednison 40 mg/day
lung with increased of for 5 days
bronchovascular Azitromycin 1 x 500
pattern suggested mg for 3 days
bronchopneumonia dd/
pulmonary TB Maintenance :
Inhaled tiotropium Br
ECG : sinus tachycardia 1 x 1 puff (morning)
with Right atrial Inhaled budesonide 2
enlargement x 1 puff
Azitromisin 1 x 250
Lab : mg
WBC : 12600 / mm3
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNI
LIST DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

male/ 60yo 2. 2.1 Peptic - Endoscopy Inj. Omeprazole 1 x VS

Ax: Dyspepsia ulcer (EGD) 40 mg IV complain
Epigastric pain, worse if 2.2. Ca. - Urea breath
having late lunch or late
syndrome
Gaster test
dinner. Nausea (+), 2.3. Gastritis
vomitting (+). History
of traditional herbal
medicine consumption
to relieve his fatigue,

Alarm Symptom:
Anemia

PE:
Abd : flat, soepel, bowel
sound (+) N,
tenderness in
epigastrium region
CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING PLANNI
DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

male/ 60yo 3. Normochrom 3.1 - Blood smear Confirm Dx VS

Ax: normocytic Chronic + reticulocyte complain
Weakness Anemia disease count
(Anemia - Faeces
PE: of analysis +
Eye : anemic (+) ikteric
(-)
Inflamatio Occult blood
n) examination
Lab : 3.2 acute
Hb : 10,9 g/dl Blood loss
MCV : 75,1
MCH : 26,3
 Present conditions

SOB (+) , cough (+) sputum (+)

GA : good GCS E4V5E6
BP : 120/80 mmHg
HR : 92 tpm
RR : 22 tpm
Thank you
Terapi
 Mechanism of Anemia in AI

RBC destruction: increased erythrocyte destruction is

caused by the activation of hosts factors such as
macrophages that prematurely remove aging
erythrocytes from the bloodstream. The explanation is
consistent with the predominance of young
erythrocytes in AI.
Suppressive effects of inflammation on erythropoietic
precursors: chiefly tumor necrosis factor (TNF)-, IL-1,
and the interferons, exert a suppressive effect on
erythroid colony formation.
 Inadequate erythropoietin secretion and resistance to
erythropoietin: In support of the EPO suppression
hypothesis are experiments with EPO-producing cell
lines indicate that production of the hormone is inhibited
by inflammatory cytokines including TNF- and IL-1.
The inhibition is mediated by the effects of the
transcription factor GATA-1 on the EPO gene promoter,
and the suppression of EPO production can be reversed
by a GATA inhibitor. Moreover, both baseline and
hypoxia-induced EPO gene expression is suppressed in
rats treated with 551 Chapter 37: Anemia of Chronic
Disease bacterial lipopolysaccharide or IL-1 to mimic a
septic state. However, suppression of EPO production is
not the major mechanism of AI.
Erythropoiesis restriction as a result Of iron
unavailability