MORNING REPORTDepartment of Internal

Medicine1.12.2014

Ny Sukesih , syok sepsis

Name : Ny. S Age : 68 y.o Sex : Female Adress : Lamongan Date : November, 3 rd 2014

IDENTITY

CHIEF COMPLAINT: weakness of the body PRESENT ILLNESS HISTORY :Weakness of the body since 12 hours before admission. Then family

of the patient bring her to the nurse, and said to be low blood pressure with sistolic blood pressure 60 mmHg.

Vomiting -, nausea-, diarrhea-, fever-, cough-, shortness of breath. The patient admitted to the RSML and her conciousness decreased.Patient decreased her appetite since 2 days before admission. Shortness of breath when the patient walked since 3 months ago.

Slept with 2 thin pillow without shortness of breath. Never woke up because of abrupt shortness of breath

ANAMNESIS

• PAST ILLNESS HISTORY: Hospitalized in intensive care unit because of AKI

and ARDS COPD + DC FC II History of DM denialHistory of HT denialHistory of 6 month treatment , her family said that finished already• FAMILY ILLNESS HISTORY: -• HYSTORY OF MEDICINE : -• Social history : • Consumption of herbal medicine denial

VITAL SIGN :GCS : 225 after loading 1000

cc 456 next 1 hours 225 BP : 69/37mmHg after

loading 1000 cc 112/67PULSE RATE : 95 x / minutesTEMP : 37oCRR : 28x / minutes

PHYSICAL EXAMINATION

Head and Neck : Anemic (-/-), Icteric (-/-), Cyanosis (-/-), Dyspneu (-), LP +/+, pupil isokor 3 mm / 3 mm.

Pulmo:Inspection : symmetrical, retraction ( -/-), tachypneu +

- Percussion : sonor - Auscultation: • Lung Sounds : Peripheral

pulmonary vesicular field • Additional sound : crackles ( +/+ ) wheezing ( - )

• Inspection : Voissure cardiac ( - ) , epigastric pulsation ( - )

• Auscultation : S1S2 single, murmur ( + ) pansistolik , gallop (-)

Cor

• Abdomen :I : flat, vena colateral (-), P : soepel, met -, Liver and spleen not

palpable, tenderness -P : shiffting dullness (-)A: Bowel sound (+) Normal

• Extremity : dry, warm, red CRT < 2, Swelling (+) minimal, eritema palmaris (-)

• Female, 68 years old• Decreased of

conciousness• Hypotension • Tachypneu• Murmur pansistolik• Decreased of

appetite since 2 days ago

• Dypsneu d’effort

History of hospitalized with ARDS

Clue and Cue

Susp. Cardiogenic shock DD Septic shock Susp. Susp. Decompensatio cordis

Assesment

CBCLFTRFT Elektrolite serumBlood gas analize Cardiac marker

Planning Diagnose

• Diffcount 0/5/88/3/4 Be 3,0• Hematokrit 40,6% Beecf 5,0• Hemoglobin 13,2 mg/dl cHCO3 31,7• LED 5/7 Clorida 94,5• Leukosit 18000 PCO2 68,2 • Trombosit 102.000 pH 7,285• SGOT 2733 U/L PO2 171,1• SGPT 1380 U/L SO2 99,3• GDA104 mg/dl• Kalium 4.5 • Natrium 138• Clorida 100• Urea 120• Serum creatinin 3,8• CK 382• CKMB 13,63

Laboratorium

Cardiogenic shock DD Septic shock with MODS

Susp.Rheumatic Heart Disease Ischemic heart disease NSTEMI

Re-Assesment

O2 NRM 10 lpm IVFD Asering loading 1000 cc 1500cc/24hour Attach cateter Inj arixtra 1x1 sc Inj ampicilin sulbactam 3x1 Clopidogrel loading 300 mg 1x1 Aspirin loading 300 mg 1x1

Consult internist

Planning Therapy

Vital signs Complaint Urine production

Monitoring

Dubia ad bonam

Prognosis

Explaine to the family about the disease, about its theraphy and intervention will be done, and also about complication and prognosis.

Education