MORNING REPORTThursday, November 5th, 2015

COASS IN CHARGE:Ricky Randana

Dadik Ardhi Wijaya

SUPERVISOR : dr. Gatoet Ismanoe, Sp.PD

SUMMARY OF DATABASEMr. S / 76 yo / W.26History Taking: HeteroanamnesisChief Complain: Decrease of ConsciousnessHistory of Present Illness :

Patient came with the chief complain decrease of consciousness since 1 month ago, it was gradually onset. He started difficult to communicate to his family then his son said he could not wake him up and he only lying on bed for 1 month worsening since 4 days before admission. Patient also complained cough since one month ago with sputum but hard to excrete, but there was no fever.

Previously, he got accident about 6 months ago when he repaired his house, then he fell, he got closed fracture and operation. After 3 month, he got repair for the fracture. He complained decreased of appetite since 3 months ago he took only small amount of food. (3-4 times, 5 spoon each time) and decreased of body weight about 10 kg in last 6 months. He also had wound in his back, hip, and also his right ear about 3 months ago. He cannot move his right leg for 3 months.

History of past illness : He was hospitalization 2 times. First about 6 months ago due to an accident and he was got an operation and the second times about 3 months ago because of repair post fracture operation . Family History : none of his family had a chronic disease Social History : Married with 4 child, and 5 grandchild. Pensionary. His daily activity was normal before he got an accident (6 months ago).

Physical Examination

BP: 140/70 mmHg PR : 100 regular strong RR: 28 tpm Temp.(ax): 36.80C

General Appearance : Looked severely ill GCS : 345Looked underweight

Head Anemic conjunctiva (+) Icteric sclerae (-) Wound at right auricular with necrosis tissue

Neck JPP R+0cm H20

Chest Heart ictus visible and palpable at ICS V, MCL SLHM – ictus RHM – SL D S1S2 single, murmur (-)

Lung Symmetric; SF D=S; S| S V | V Rh - - Wh - - S| S V | V - - - - S| S BV | V + - - -

Abdomen Flat, bowel sound normal, liver span 8 cm, Traube’s space tympani

Ext. Warm acral . Turgor ↓, dry skin (+)Wound at right hip, his back with excoriation and necrosis tissue, hiperemis, kalor (+)

Photo

Photo

LABORATORY FINDINGSLab Value Lab Value

Leucocyte 12140 4000-11.000/µL Na 140 136-145mmol/l

Diff count 0.0/0.0/88.3/8.4/3.3

0-4/0-1/51-67/25-33/2-5 %

K 4.34 3,5-5,0 mmol/l

Haemoglobin 8.20 11-16,5 g/dL Cl 113 98-106 mmol/l

MCV 89.40 80-93 fl

MCH 31.00 27-31pg Ureum 139.70 16,6-48,5 mg/dL

PCV 20.2% 40-47 % Creatinin 3.17 < 1,2 mg/dL

Thrombocyte 86000 142-424 1 x103/µL BUN/Cr 20.59

SGOT/AST 31 11-41U/L

SGPT/ALT 11 11-41U/L RBS 135 < 200 mg/dL

Albumin 2.30 3,5-5

PPT / INR 12.00/11.2

APTT 22.80/27.50

URINALYSIS Lab Value Lab Value

Cloudy Cloudy Clear 10 x

Color Yellow Yellow Epitel 23.3 ≤ 1lpf

pH 5.5 4,5 - 8,0 Cilinder Negative Lpf

BJ 1030 1,010 – 1,015 Hialin Negative ≤ 2

Glucose Negative Negative Granular Negative Negative

Protein +1 Negative 40 x

Keton Negative Negative Erythrocyte 2,7 hpf ≤ 3 hpf

Bilirubin Negative Negative Dysmorfic Negative Hpf

Urobilinogen Negative Negative Eumorfic Negative Hpf

Nitrit Negative Negative Leucocyte 283.8 ≤ 5 hpf

Leucocyte +3 Negative Fungi - Hpf

Blood +2 Negative Bacteria 1582.3 ≤ 23 x 103/mL

ECG

ECG

Sinus tachycardia with HR 100 bpmFrontal axis : NormalHorizontal axis : normal PR interval : 0,20 secondQRS kompleks : 0,08 secondQT interval : 0,32 secondConclusion : Sinus tachycardia with HR 100 bpm

CXR

AP position, asymmetric, KV enough, enough inspiration Soft tissue skin, bone : normal Trachea in the middle Hemidiaphragm D /S dome shape Phrenico cotalis angle Dextra & sinistra are sharp Pulmo D/S : infiltrate Cor site: N, Size: CTR 46 %Conclusion : Susp. Pneumonia

Chest X-Ray

CUE AND CLUE PL Idx PDx PTx Pmo

Male/ 76 YO/ Ward 26DOCProlonged bedriddenCough Multiple ulcus decubitusLow intake Geriatric problem

Phy. ExamGCS: 345BP: 140/70mmHgPR: 100 bpm RR: 28 tpmT.ax: 36.8 C

LabHb 8.20Leuco 12.140Ur/Cr: 139.70/3.17

UL Leucocyte : 283.5

Cxr: Susp. Pneumonia

1. DOC 1.1 Septic encephalopathy

1.2 Uremic encephalopathy

02 8 - 10 lpm via NRBM

Inj. ceftriaxone 2x1 g

Inf. Levofloxacin 1 x500mg 1x250 mg Intravena

Rehydration 2000cc in 2 hours maintenance 20 tpm

VSSubjectiveUrine output

Male/ 76 YO / W.26DOC, low intake , multiple ulcus decubitus due to prolonged bedridden

Phy. ExamBP: 140/70mmHgRR: 28 tpmPR: 100 bpmT.ax: 36.8

-Rhonki in basal dextra lung (+)-Multiple ulcus in hip dextra, auricular dextra with necrotic tissue (+)

LABLeuko : 12140Trombo 86000UL: Leuco 238.5

CXR : Susp. Pneumonia

2. Septic condition

2.1 Ulcus decubitus gr II due to prolonged bed ridden

2.2 Pneumonia 2.2.1 CAP2.2.2 Orhtostatic

2.3 UTI

Culture sputum , pus, and antibiotic sensitivity test

Bedrest with proper position and antidecubitus bed

Equal fluid balance

Inj ceftriaxone 2x1 gram

Inf. Levofloxcacin 1 x500mg 1x250 mg Intravena

Wound toilet

VS SubjSeptic shock sign

Male/ 76 YO / w26DOC, prolonged bedridden, wound at auricular and right hip, ulcus decubitus

Phy. Exam:Anemic conjunctiva (+)

LABHb: 8.20MCV: 89.00MCH: 31.00

3. Anemia NN

3.1 Chronic disease

3.2 Occult blood loss

Treat underlying disease

Subj, vital sign, Recheck cbc

Male/76 yo/W26Ax:DOCProlonged bedridden, Low intake

Phy. ExamGCS 345BP 140/70 mmHgPR 100 bpmRR 28 tpm

Lab:WBC: 12140PLT: 86.000Ureum: 139.7Creatinin: 3.17

4. Azotemia 4.1 pre renal4.1.1 Septic condition 4.1.2 Volume depletion

4.2 Renal

•Equal fluid balance

•Liquid diet 6x200cc (1cc ~ 2 calories)

•Loading fluid at ER NS 2L in 2 hours continued NS - 20tpm

VSSubjectiveRecheck ureum creatininUrine production

Male/76 yo/ W26DOCProlonged bedridden due to post fractureLow intakeMultiple ulcus decubitusContracture due to immobilitation chronic

PE :BP 140/70mmHgPR 100 bpmRhonki in basal dextra Ulcus decubitus with necrotic tissue

LABAlbumin : 2.30 g/dLLeucocyte 12140 mg/dLGDS 135

CXR: Pneumonia

5. Geriatric problem

5.1 Prolonged bed ridden

5.2 Immobilization

5.3 Constipation

5.4 Malnutrition

Proper positioning every 2 hours with antidecubitus bed

Medical rehabilitation

Inserted NGT diet: need 2100 kcal/day 6 x 200cc + extract protein

IVFD NS 1000cc / day

SubjVSUrine output