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MORNING REPORT

Friday, October 14th 2011


PHYSICIAN INCHARGE: IA : dr. Ade, dr. Herwindo, dr. Aditya, dr. Widyo IB : dr. Rusyda, dr. Eric II : dr. Rofika III : dr. Shinta Octya, SpPD

Summary of Data Base


Mr. moersiadi /74 y.o/W 24b Chief Complain : decrease of consciousness Patient became unconscious 12 hours before he

arrived at RSSA. He also had excessive sweating. 1


hour before unconscious, he injected insulin 22iu but he forgot to eat after that. He has been diagnosed as diabetes since 2008. he routinely controlled to out patient of endocrine department and got insulin 24iu at night and 22iu before meal.

Summary of Data Base


He also said that his blood pressure usually was 150/ Patient sometime had cough since 1 month ago. He

was diagnosed having TBC in 2010, and already


finished his treatment for 6 month. The last CXR (29 dec 2010) showed bekas KP. He denied about decreased of body weight. He did not smoke.

Physical examination
BP = 150/90mmHg PR = 84 bpm RR = 18 tpm General appearance looked moderately ill GCS 111456 Looked normoweight Head Neck Thorax: Heart: Anemic Icteric -

JVP R + 0 cmH2O; 30 Ictus invisible and palpable at ICS V MCL sinistra LHM: ictus RHM: SL S1, S2 single with no murmur Symmetric, SF D = S s s ss ss v v v v v v Rh - - - Wh - ---

Lung:

Abdomen

Soefl, liver span 8 cm, troube space tympani, bowel sound normal Warm

Extremities

Laboratory finding
Lab Value Lab Value

Leukocyte
Haemoglobine PCV

13,200
14.8 45

3.500-10.000/L
11,0-16,5 g/dl 35-50%

Natrium Kalium

152 3.91

136-145 mmol / L 3,5-5,0 mmol / L


98-106 mmol / L 11-41U/L

Chlorida 111 RBS 15 SGOT 27

Trombocyte
Ureum Creatinine

267,000
40.6 0.87

150.000390.000/L
10-50 mg/dL 0,7-1,5 mg/dL

SGPT
Alb CPK CKMB Trop I

18
4.17 200 27 - (0.1)

10-41U/L

ECG (14/10/2011)
Sinus rhythm, heart rate 68 bpm Frontal Axis : Normal Horizontal Axis : Normal PR interval : 0.12'' QRS complex : 0.04 QT interval : 0.32

Conclusion : Sinus rhythm with heart rate 68 bpm

CXR 141011

CXR (14/10/2011)
AP position, asymmetric Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and hemidiaphragm are dome-shape Aortic knot + Lung: thickening of hillus D/S, fibroinfiltrat in medial area of the lung, infiltrat in apex Cor site, shape are normal, with CTR 46% Conclusion: KP active

CUE AND CLUE Male/74 yo Unconscious 12 hours before admission Excessive sweating Injected insulin 22iu and did not eat 1 hour before unconscious Had been diagnosed diabetes since 3 years ago got insulin GCS 111 456 BP: 150/90 PR: 84 RR: 18 RBG: 15 Leukocyte 13,200 1.

PL Hipogli cemia state

IDx 1.1 due to insulin

PDx

PTx D40% 50mL (iv) IVFD NS 20dpm Free diet Stop insulin

PMo Subjective VS GCS RBG 15 minutes after correction and serial

CUE AND CLUE Male/74 yo Had been diagnosed diabetes since 3 years ago got insulin as his treatment GCS 111 456 BP: 150/90 PR: 84 RR: 18 RBG: 15 Leukocyte 13,200

PL 2. DM type 2 normo weight on insulin

IDx

PDx

PTx Insulin postponed

PMo FBG 2hppBG

Male, 74yo Had history having blood pressure 150/.. Without theraphy BP 150/90 Male, 74 yo Chronic cough Diagnosed as TBC 1 year ago CXR active KP

3.Hyperten sion stage 1

3.1 Autonomic neuropathy due to DM type 2 3.2 atherosclerosis HT 4.1 KP active

Fundusco py Lipid profile

Low salt diet

Subjective BP

4. Chronic lung inf

sputum culture AFB SPS

Confirmed diagnosed

Subjective VS

Thank you

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