Summary of Data Base

Mr. A/ 47 yo/W. 22

Chief complaint: Nausea and vomiting

Patient suffered from nausea and vomiting and decrease of appetite

since one week before admission. Nausea appeared when he take a meal
and sometimes vomit contain of residual fluid and food. Vomit 2-3 times
per day, not projectile. Because of this patient just eat about five spoon
every meal.

Patient also felt abdominal discomfort on his epigastrial and

sometimes felt pain, with warm and stabbed sensation not radiculated that
relieved by food. No history of coffee ground vomiting and no history of
blacktarry stool
 Patient suffered from general weakness since one week ago and
worsening in the last three days felt on the whole of body. Initially one
week before felt this complaint, the patient still can do the activity like
usually, even the heavy activity but in the last 3 days the patient felt
general weakness and difficult to doing daily activity like walk upstair or
walk > 100 meters.

Patient has diagnosed diabetes mellitus since five months ago at

wava husada hospital, and got some drugs but the patient forget the name
of that drug. Actually patient routinely controlled at that hospital but in the
last one month patient didn’t controlled and took the drug not regularly.
 History of past illness:-
• Social history :
– Married with two children, work as government
employee
– Regularly consumed traditional potion if he start
to felt pain on his body after he got worked.
– Smoker, since young, 6 bar per day
• Family history :
– No history of diabetes mellitus nor hypertension
 Physical examination
BP = 110/50 PR = 80 bpm, regular strong RR = 16 tpm Tax : 35,8 °C
mmHg
General appearance looked moderately ill, GCS 456 look normoweight

Head Pale conjunctiva - Icterus Sclera -

Neck JVP R + 2 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS V MCL Sinistra

LHM ≈ ictus
RHM: SL D
S1, S2 single, murmur -

Lung: Symetric, SF D= S s s Rh - - Wh - -
s s -- --
s s -- --
Abdomen Flat , soefl, bowel sound (+) normal, , liver span 8 cm, traube space
tympani

Extremities Leg Oedema -/- warm acral -/-

 LABORATORY FINDINGS
Lab Value (Normal) Lab Value (Normal)
Leukocyte 6400 4,7 - 11,3 µL Natrium 122 136-145 mmol/L
Haemoglobine 16,50 11,4 - 15,1 g/dl Kalium 3,72 3,5-5,0 mmol/L
PCV 45,00 % 38 - 42% Chlorida 103 98-106 mmol/L
Trombocyte 189000 142 - 424/µL RBS 366 < 200 mg/dl
MCV 80,10 80-93 fl Ureum 41,30 20-40 mg/dL
MCH 29,40 27 - 31 pg Creatinine 0,65 <1,2 mg/dL
BUN/Cr 19,29
SGOT 13 0-32 mU/dL Eo/Bas/Neu 0.8/0.6/66 0-4/0-1/51-
/limf/Mon ,1/28,3/4, 67/25-33/2-5
2
SGPT 16 0-33 mU/dL osmolarity 271,2

3.5-5.5 Na corrected 126.25

 BGA
BGA Value
(Suplemental O2 10 Lpm)
PH 7,23 7,35-7,45
PCO2 11,7 35-45
PO2 144,9 80-100
HCO3 5,0 21-28
O2 saturation 98.9 % > 95%
Base Excess - 22,8 -3 until +3

Conclussion Acidosis Metabolic with uncompensated alkalosis

respiratoric
Urinalysis
Lab Value Lab Value
Urinalysis 10 x
SG 1,030 Epithelia -

PH 6.0 Cylinder -

Leucocyte Negatif Hyaline -

Nitrite Negatif Granular -

Leukocyte -
Protein Trace
Glucose +2 Erythrocyte -

Erythrocyte +2 40 x
Erythrocyte 7 - 10

Keton urine +3 Leukocyte 2-3

Urobilinogen - Crystal -
Bilirubin - Bacteria Positif x 10
ECG
 ECG

• Sinus rhythm, Heart rate 75 bpm

• Frontal Axis :N
• Horizontal Axis : N
• PR interval : 0.16”
• QRS complex : 0.08”
• QT interval : 0.36 ”

• Conclusion : sinus rythm with heart rate 75 bpm .

CXR
 CXR

• AP position, asymmetric, enough KV, enough inspiration

• Soft tissue normal, Bone normal
• Trachea in the middle
• Hemidiaphragm D and S is dome-shaped
• Phrenico vostalis angle D and sinistra are sharp, Pulmo D/S
bronchovesikular pattern not increased
• Cor: Size and site normal, ctr 47 %

Conclusion : normal cardiac x ray

 CUE AND CLUE PL IDx PDx PTx PMo
Male/ 47 yo/w 22 1. Mild Keton O2 8- 10 lpm NRBM S, VS,
A: KAD plasma Fasting UOP
•Nausea IVFD NaCl 0,9 % 20tpm RBG/h
•Vomiting Rehidration NaCl 0,9 r, SE /4
•Decrease of appetite %1L hr ,
• General weakness BGA
•History of DM 5 months ago Line 1: Drip insulin short /6 hr
uncontrolled acting 5 IU/hour
• PE: Line II : IVFD NaCl 0,9%
GCS : 456 20 tpm
BP : 110 / 60 mmHg If RBG < 200 mg/dL
PR : 80 bpm Line 1: Drip insulin short
RR : 16 acting 2.5 IU/hour
Tax : 35,8 °C Line II : IVFD D5
Lab Finding : 1/2NS 20 tpm
RBG : 366 Monitoring calium level
Na/K/Cl : 122/3,72/103
Anion Gap: 14 If RBG < 150-200 mg/dL
BGA : Acidosis metabolic
UL : keton (3+) , Glucose (+), Inj intermediate acting
erythrosit (2+) insulin 10 IU sc
Inj short acting insulin 4-
4-4 IU sc
Stop drip 2 housr after
basal insullin
administrated
CUE AND CLUE PL IDx PDx PTx Pmo P.Ed

Male /47yo/ward 22 2. Diabetes After KAD resolve : Hba1C

Ax: Mellitus •Diet Diabetes Mellitus 1900 RBS
General weakness type 2 kkal/day
Nausea and vomiting •Considered to make a insulin
Epigastric pain
Decrease of appetite
History of Diabetes
mellitus since 5 months

PE:
GCS : 456
BP : 110 / 60 mmHg
PR : 80 bpm
RR : 16
Tax : 35,8 °C
Lab Finding :
RBG : 366 --- 200

Male/47 yo/ward 22 3. 3.1 low intake Rehydration as above (IVFD NaCl Rechec
•Nausea Hyponatre 0.9% I liter) k
•Vomiting mia
•Decrease of appetite Normoosm
olar
•Lab : Hypovolemi
•Natrium : 122 a
Thank You