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    Morning Report: Dr. Dikara WS Maulidy, SP - PD

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    Bethari Abi Safitri
    1) Mrs. F, a 54-year-old female, presented with weakness in her right upper and lower extremities for 3 days along with swelling in both feet. She has a history of diabetes. 2) On examination, she had elevated blood pressure, abnormal lab results including hyperglycemia and leukocytosis, and neurological exam found reduced strength in the right extremities. 3) Imaging showed a lesion in the left basal ganglia and old infarct in the left occipital lobe. She was diagnosed with severe hyponatremia and treated with IV fluids and medications.

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    Morning Report: Dr. Dikara WS Maulidy, SP - PD

    Uploaded by

    Bethari Abi Safitri
    90 views24 pages
    1) Mrs. F, a 54-year-old female, presented with weakness in her right upper and lower extremities for 3 days along with swelling in both feet. She has a history of diabetes. 2) On examination, she had elevated blood pressure, abnormal lab results including hyperglycemia and leukocytosis, and neurological exam found reduced strength in the right extremities. 3) Imaging showed a lesion in the left basal ganglia and old infarct in the left occipital lobe. She was diagnosed with severe hyponatremia and treated with IV fluids and medications.

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    Morning Report

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    1) Mrs. F, a 54-year-old female, presented with weakness in her right upper and lower extremities for 3 days along with swelling in both feet. She has a history of diabetes. 2) On examination, she had elevated blood pressure, abnormal lab results including hyperglycemia and leukocytosis, and neurological exam found reduced strength in the right extremities. 3) Imaging showed a lesion in the left basal ganglia and old infarct in the left occipital lobe. She was diagnosed with severe hyponatremia and treated with IV fluids and medications.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    90 views24 pages

    Morning Report: Dr. Dikara WS Maulidy, SP - PD

    Uploaded by

    Bethari Abi Safitri
    1) Mrs. F, a 54-year-old female, presented with weakness in her right upper and lower extremities for 3 days along with swelling in both feet. She has a history of diabetes. 2) On examination, she had elevated blood pressure, abnormal lab results including hyperglycemia and leukocytosis, and neurological exam found reduced strength in the right extremities. 3) Imaging showed a lesion in the left basal ganglia and old infarct in the left occipital lobe. She was diagnosed with severe hyponatremia and treated with IV fluids and medications.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 24

    MORNING REPORT

    Tuesday , 5th of Desember 2017

    Presented By :
    Bethari Abi Safi tri, S.Ked
    M. Fathir Naman Harris, S.Ked
    Yulia Fitriani, S.Ked

    DOCTOR INCHARGE:
    Dr. Dikara WS Maulidy, Sp.PD
    PATIENT IDENTITY

     Name : Mrs. F
     Sex : Female
     Age : 54 yo
     Religion : islam
     Tribe : Banjar
     Nation : Indonesia
     Address : sungai baru no 6 RT 02 RW 01
     Date of Hostipitalization : 10th December 2017
    AUTOANAMNESIS
    CHIEF COMPL AINT : EXTREMITY WEAKNESS

    Patient complained about weakness of her upper and


    lower right extremity since 3 days before admission. She
    cannot move her right hand and right foot. Before, she felt
    that both of her foot was swelling. She declined of having
    trauma before these complains.
    she also complained about wound in both of her sole. This
    wound appear couple days after she didn’t use shoes while
    walking.
    she admits having diabetes melitus for 1 year and went
    to doctor. She have got 4 diff erent anti diabetics and insulin
    but she only use the oral medicine and seldomly using the
    insulin
    she never had this kind of symptomp and sign
    before.
    HETEROANAMNESIS
    ry of past illness: unknown
    History of family illness: unknown
    History of drug: No drug abuse or addiction,
    patient no drinks alcohol
    Allergic History : No allergic history
    Smoking History: No smoking history
    Social History: Patient lives with her
    husband and son
    PHYSICAL
    EXAMINATION
    BP = 160/100 Pulse rate = RR = 21 tpm Tax : 36,8 C
    mmHg 98 bpm
    Regular,
    normal
    General appearance looked GCS E4V5M6
    mildly ill
    Head Pale conjungtiva Acetone breath odor
    (+) Icteric (-)
    Visus ; 0

    Neck JVP (-) lymph node enlargement (-)


    Thorax: Ictus invisible, palpable at ICS V lateral MCL sin
    Cor: LHM : Ictus RHM : ICS 3 PSL dextra
    S1 S2 single, murmur (-)
    Symmetric, S S V V Rh - - Wh - -
    Lung: S S V V - - - -
    S S V V - - - -
    Abdomen palpable abdomen mass , abdominal pain (-)
    Bowel sound (+) shifting dullnes (-), fluid wave (-),
    striac (-)
    Extremities Pitting edema (-), cold acral (-), palmar and plantar
    icteric (-)
    Wound at plantar pedis sinitra et dextra
    Abi
    Wegner
    Pedis
    NEUROLOGICAL EXAMINATION

     Meningeal sign (-)


     Sensoric examination Normal
     Motoric examination Upper 3/5 lower 3/5
     Physiologic refl ex Normal
     Pathologic refl ex Babinskiy (+/?)
    LABORATORY RESULT
    (MAY 9 T H , DECEMBER 2017)
    Test Result Range Units
    HEMATOLOGY
    Hemoglobin 12,6 12.00-16.00 g/dl
    Leukocyte 14,7 4.00-10.5 thousand/ul
    Erythroyte 3,96 4.00-5.30 Millionul
    Hematocrit 35,7 37.00-47.00 Vol%
    Trombocyte 279 150-450 Thousand/ul
    RDW-CV 13.0 12.1-14.0 %
    MCV, MCH, MCHC
    MCV 90,3 75.0-96.0 fl
    MCH 31,8 28.0-32.0 pg
    MCHC 35,2 33.0-37.0 %

    Leukocytosis,
    Test Result Range Units

    Deep Count

    Gran% 85.9 50.0-70.0 %

    Limfocytes% 7.8 25.0-40.0 %

    MID% 6.3 4.0-11.0 %

    Gran# 12.70 2.50-7.00 Thousand/ul

    Limfocytes# 1,1 1.25-4.0 Thousand/ul

    MID# 0,9 Thousand/ul

    Glucose

    Random Plasma Glucose 646 <200 Mg/dl

    Liver

    SGOT 31 0-46 U/l

    SGPT 22 0-45 U/l

    Kidney

    Ureum 50 10-50 Mg/dL

    Creatinine 1.1 0.6-1.2 Mg/dL


    Increase of gran %, lymfopenia, hyperglichaemia,
    increase of granulosit count, decrease of lympocyte
    Items Result Normal Value
    Natrium 129.6 135-146 mmol/l
    Kalium 4.7 3.4- 5.4 mmol/l
    Chlorida 97.5 95-100 mmol/l

    Osmolarity = 2 ( Natrium + Kalium ) + (GDS/18) + (Ureum/6.4)


    = 2 ( 129,6+4.7) + (646/18) + ( 50 : 6,4 )
    = 312,21 mOsm/L

    Hyperosmolar hyponatremia
    Items Result Normal Value

    Urinalysis
    -Appearance Clear yellow Clear yellow
    -Specific gravity 1.020 1.005 – 1.030
    -pH 6.5 5.0-6.5
    -Ketones +3 Negative
    -Protein-albumin +2 Negative
    -Glucose +3 Negative
    -Bilirubin Negative Negative
    -Blood +3 Negative
    -Nitrite Negative Negative
    -Urobilinogen 0.1 0.1-1.0
    -Leukocyte Negative Negative
    Items Result Normal Value

    Urinalysis (sedimen)
    -White blood cells 1-2 0-3
    -Red blood cells 0-1 0–2
    -Silinder Negative Negative
    -Epithel +1 +1
    -Bacteria Negative Negative
    -Crystals Negative Negative
    -Others Negative Negative
    CXR (DECEMBER, 9 T H 2017
    INTERPRETATION OF CXR

     Position AP
     Enough QV
     Enough inspiration
     No tracheal deviation
     Soft tissue and bone are normal
     Bronchovasculare pattern is increased
     No fi brosis
     Hemidiphragma dome shape
     Costophrenicus angle dextra and sinistra is sharp
     Cardiophrenicus angle dextra and sinistra is sharp
     CTR 58%
    ECG (DECEMBER , 10 T H 2017)
    INTERPRETATION OF ECG

     Sinus, rhythm
     HR : 94 x/m
     Frontal axis : normal axis deviation
     Horizontal axis : counter clock wise rotation
     PR interval : 0,16 s
     QRS duration: 0,08 ms
     T wave normal
     ST elevation (-)
     There is left ventricular hypertrophy
     Conclution : Sinus rhythm, rate 94 bpm, normal axis, LVH.
    HEAD CT SCAN
     There is a hipodens
    lesion on ganglia basalis
    sinistra
     There is a old infark on
    occipital lobe sinistra
    POMR
    CUE AND CLUE Problem IDx PDx PTx Pmo Ped
    List
    Female/ 54yo Severe After 20 Diet : low
    hiponatrem NS 3% 150 ml minutes of fluid
    A ia during 20 minutes 3%
    Headache Ranitidine 2x50 mg Admission,
    Vomitus Purosemide 1x40mg evaluate the
    Nausea sodium
    Weakness
    irritable SE
    examination
    Laboratory
    Natrium 107 mmol/L Subjective
    hypoosmolar Vital sign

    BUN : 15,88
    CUE AND PL IDx PDx PTx Pmo Ped
    CLUE
    Female/65 yo 2. - - Nonfarmakologist : - Subject -
    A Hypertension -Diet modification - Vital sign Educational
    poorly - Change lifestyle life style
    -since couple
    treatment
    years ago, Farmakologist :
    Amlodipin 10 mg, 1
    sometimes the
    times/day (In the
    blood pressure Morning)
    was high she
    even went to
    the doctor if
    none of other
    symptoms like
    headache.

    PE:
    •TD: 160/100
    CUE AND CLUE PL IDx PDx PTx Pmo
    Female/33 yo 3. Diabetes - Non pharmachologist: • Subject • Diet
    A Melitus - Diet modification • Vital sign nephrisol
    Patient had specially for diabetic • HbA1C
    diabetes melitus - Always use sandal if • Fasting
    since couple she out from house to plasma
    years ago. protect the feet. glucose
    • Post
    Pharmachologist : prandial
    -Detemir Insulin 8 UI plasma
    Laboratorium on night glucose
    Random plasma
    glucose : 288
    Thank
    you

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