MORNING REPORT

Wednesday November 22nd 2017

Presented by:
Ahmad Rifqi Yusuf
Arsya Al Ayubi
Thalia Puteri
Ifa Febriariana
Soraya C.Z
Ervin Monica

Supervisor : dr. Fajar, Sp.PD

 SUMMARY OF DATA BASE
Mrs. M/ 61 yo/ W.Dahlia 2
Chief complain : Decrease of Consciousness
Hitory present illness
Patients come to the ER with decrease of consciousness. Decrease of
consciousness suddenly occurred 1 hour before hospital admission.
patients can not be awakened when a decrease in consciousness occurs
even when the patient's eyes are. Before the decrease of consciousness
occurs the patient can still communicate with family. the patient complained
that her body is feel weak and her body has a lot of cold sweat before
decreased of consciousness happen.
the patient has been diagnosed with Diabetes Mellitus since 1 year
ago and the highest RBS was 350. Patient routinely take OAD every day and
also routinely control to Internal medicine clinic once a month. The Anti
Diabetic Agent that given to this patient was Metformin 2x500mg and
Glimepiride 1x2mg.
the patient has no complaint shortness of breath, fever, cough,
headache, or half parese of her body.
SUMMARY OF DATA BASE cont..
Past medical history :
Patient was diagnosed with DM 1 years ago
HT (-) TB (-) Kidney Disease (-).
Social history:
Patient was a housewife. She lived with her husband. She had 3 children.
She wasnt a smoker.
Family history :
Three of her brother was diagnosed with DM too. HT(-)
Review of System :
No other complain in another system.
 PHYSICAL EXAMINATION
General appearance : looked severely ill GCS 324 -> 456 looked underweight

BP : 95/60 mmHg HR 105 bpm regular RR : 20 tpm Tax : 36,30C Sa O2 : 97%

Head Conjunctiva anemis (-/-), Sclera Ikterik(-/-), pupil isokor

Neck JVP R+0cm H2O at 30, limphnode enlargement (-)

Thorax : Cor Ictus invisible and palpable at ICS V MCL sinistra
LHM ~ ictus RHM: SL D
S1, S2 single, murmur (-), gallop (-)
Pulmo Symmetric , Percution sonor sonor v v Rh - - wheezing - -
sonor sonor v v - - --
sonor sonor v v - - --
Abdomen Flat, Soefl, bowel sound (+), liver span 9 cm and traubes space was tympani,
pain (- in all of region), shifting dullness (-),
murphy sign (-)

Extremities cold acral, dry skin (-), CRT < 2

edema -/-
-/-
 Laboratory finding (NOV, 20 th 2017)

Laboratory Result Normal Value Laboratory Result Normal Value

Hb 11.8 12 18 g/dL SGOT 16 0-40 U/L
Erythrocyte 4,03 4,0-5,5 x 106/L SGPT 14 0-41 U/L
Leucocyte 5.900 4,500-11,000/L Ureum 15 16.6-48.5 mg/dl
Hematocrit 29.3% 32 54 % Kreatinin 0.92 < 1,2 mg/dl
Thrombocyte 362.000 150.000-450.000/L Kalium 3,32 3,4 5,3

Differential 20,9/8 20-50/1-15 % Natrium 139,0 135 150

count
lim/mono
MCV 87,8 76,0 96,0 Clorida 103,0 98 -107
MCH 29,0 26,0 35,0
MCHC 33,0 30,0 35,0
RBS 34 <200
 CUE AND CLUE PL Idx PDx PTx Pmo P edu

Mrs. M/61 yo/Ward Dahlia 1. DOC dt GD1/GD2 -Bedrest Subjective The

2 Hypoglycemia -IV D20 until RBS GCS disease,
Anx : 140 -180 mg/dL Vital Sign treatme
DOC 1 hour before -IVFD D10% ~ 10 Obs RBS nt, and
admission, suddenly occurs dpm prognosi
Patient can communicate -Postponed OAD s
before DOC occurs
Before DOC occurs, patient Educate
complained feel weak and the
increase of producing cold patient
sweat to eat
the patient has been
diagnosed with Diabetes
Mellitus since 1 year ago
OAD that given to this
patient was Metformin
2x500mg and Glimepiride
1x2mg

PE:
GCS : 324 ->456
BP 95/60
Tax : 36,3
RR: 20
HR 105
Extrimities : Cold acral

Lab:
RBS : 34 mg/dL
180mg/dL
 CUE AND CLUE PL Idx PDx PTx Pmo P edu

Mrs. M/61 yo/Ward Dahlia 2. DM type 2 GD1/GD2 -Postponed OAD Subjective The
2 on OAD ~ Metformin 3 x 500mg GCS disease,
Anx : ~ Glimepiride 1x2mg Vital Sign treatme
The patient has been Obs RBS nt, and
diagnosed with Diabetes prognosi
Mellitus since 1 year ago s
the highest RBS was 350
OAD that given to this
patient was Metformin
2x500mg and Glimepiride
1x2mg
Three of her brother was
diagnosed with DM too

PE:
GCS : 324 ->456
BP 95/60
Tax : 36,3
RR: 20
HR 105

Lab:
RBS : 34 mg/dL
180mg/dL
 Condition This Morning
GCS : 456
BP : 120/90 mmHg
HR : 80 bpm
RR : 20 tpm
Tax : 36,6 C
SpO2 : 98%
 THANK YOU