Lapjag 30 Maret

Morning Report
March 30, 2021

1. Refit anggra yoni, male, 23 YO
} CC:
◦ Abdoment enlargement since 1 month ago
} Present Illness History
◦ Abdoment enlargement since 1 month ago and
increase 1 week ago
◦ Swollen at foot since 1 months ago
◦ Fatique since 1 week ago
◦ Nausea (+), vomiting (-)
◦ Swollen at foot since 1 months ago
◦ Already diagnosed with CKD ec GNC on HD in 3
years ago in the previous hospital HD routine since 3
years ago, in Tuesday and Friday
} Past Illness History
v History of Hipertension (+)
v History of DM (-)
v History of malignancy (-)
• Family Illness History

v No patient’s family had the same illness
Physical Examination
} Consciousness level: CMC
} BP : 154/72 mmHg
} HR : 88x/minute
} RR : 22x/minute
} T: 36,90 C
} Skin : turgor was normal
} Limph Gland : No enlargement
} Eye
} Conjunctiva are anemic +/+
} Sclera are icteric -/-
} Neck
} JVP 5+2 cmH20
} Lung:
} Inspection: simetric in static and dinamic
} Palpation: fremitus left=right
} Percussion: sonor
} Auscultation:Vesicular, Rales -/-, wheezing -/-
Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at LMCS ICS VI
◦ Percussion:
Left border: 1 finger lateral LMCS ICS VI
Right border: linea sternalis dextra
Upper border: RIC II
◦ Auscultation: pure rhythm, no murmur,

} Abdomen:
} Inspection: enlargement (+)
} Palpation: liver and spleen hard to assess, undulation
(+)
} Percussion: dull (+)
} Auscultation: bowel sound (+) normal
} Extremities:
} Physiologic Reflex +/+
} Pathologic Reflex -/-
} Oedema +/+
Laboratory
Hb 7,1 g/dL
Ht 22%
WBC 5130/mm3
Platelet 343000/mm3
Ur/creatinin 83/10,4
Na/K/Cl 131/4.8/107
Total protein 6,4
Albumin/globulin 3,1/3,3
Calcium 8,7
Ur/cr 83/10,4
ECG
Chest X Ray
Working Diagnose
} Nefrogenic ascites
} CKD stg V ec GNC on HD
} Congestive heart failure Fc II
} Moderate anemia normositik normokrom ec
chronic disease
Therapy
} Rest/ heart diet, RPRG
} Folic acid 1x5 mg
} Bicnat 3x500 mg
} Candesartan 1x16 mg
} Amlodipin 1x5 mg
Planning
} Parasintesa ascites
} Ascites analatysis
} Abdominal USG
2. Herryanto, 58 yo, male, mW 16
} Chief Complaint:
} Pro chemoteraphy 1st cycle
} Pro chemotheraphy 1st cycle, patient has been known with
chronic lymphocytyc leuchemia since 1 month ago.
} Abdomen was enlargement since 1 year. Fullness in the
stomach since 1 year ago.
} Swelling on the right and left neck with a size of marble.
} Fatigue and weakness since 1 month ago.
} Paleness since 1 month ago.
} Bleeding hystorical (-)
} Micturition in normal limits, Defecation in normal limits,
bloody stool (-).
Past illness history
} History of HT denied
} History of DM denied
} BP : 110/70 mmHg
} HR : 74 x/minute
} RR : 19 x/minute
} T: 36,8 C
} Eye
} Anemic conjunctiva (+)
} Icteric sclera(-)
} Neck
} JVP 5-2 cmH20
} Palpable mass diameters 1,5cm at submandibula sinistra.
} Multiple mass diameter 1 cm at posterior
Lung:
} Inspection: normochest
} Palpation: fremitus equal on both side, palpable marble sized
mass in the left axilla
} Percussion: sonor
} Auscultation: vesicular, rales -/-, wheezing -/-
} Cor:
} Inspection: ictus is not seen.
} Palpation: ictus is palpated at 1 finger medial LMCS ICS V
} Percussion:
} Left border: 1 finger medial LMCS ICS V
} Right border: linea sternalis dextra
} Upper border: ICS II
} Auscultation: regular rhytm, murmur (-)
} Abdomen:
} Palpation: Liver palpated 2 finger inferior arcus costae
dextra, Spleen S2
} Percussion: tympani
} Auscultation: bowel sound (+) N
} Extremities:
} Capillary refill time >2 sec
Laboratory findings
Hb 6,9 gr/dl
Ht 23 %
WBC 20.860/mm3
Platelet 210.000/mm3
Reticulocyte 2,9
DC 1/4/1/11/82/1
MCV/ MCH/MCHC 82/24/30
Ur/Cr 15/1,0
Na/K/Cl 137/3,8/108
SGOT/SGPT 9/6
GDS 130
Ro thorax
Working Diagnosis
} Chronic Lymphositic Leukemia pro chemotheraphy 1st
cycle
} Moderate anemia normocytic normochrome cb
malignancy
} Hypoalbuminemia
Therapy
} Rest/ Daily diet High energy protein
} IVFD NaCl 0,9% 8 hrs/kolf
} B complex 2x1 tab p.o
} Paracetamol 3x500mg p.o prn
} Crossmatch PRC 2 units
} Transfusse PRC 1 unit /day.
plan
} Check hepatitis marker
} Protocol chemoteraphy
3. Andri,29 yo, male, mW 16
} Chief Complaint:
} Fatigue and weakness increased since 5 days ago
} Fatigue and weakness increase since 5 days ago
} Fatigue increased since 3 days ago. this complain had been felt
since 2 weeks ago
} Fever (-) Cough (-) Breathlessness (-)
} Decrease of appetite (-)
} Nausea and vomit (-)
} Bloody stool (-)
} Urine was normal
} Patient has known as Thalasemia since 8 years ago and regularly
receive blood transfusion
} History of hypertension and DM type 2 was denied
} General Appearance : Moderate
} BP : 117/66 mmHg
} HR : 87 x/minute
} RR : 18 x/minute
} T: 37º C
} Eye
} conjunctiva anemic (+)
} Icteric sclera(-)
} Neck
} JVP 5-2 cmH20
} Lung:
} Inspection: statically & dynamically symmetric
} Palpation: fremitus right=left
} Percussion: sonor
} Auscultation: vesicular, Rh -/- Wh -/-
} Cor:
} Palpation: ictus is palpated at 1 finger medial
LMCS ICS V
} Percussion:
} Left border: 1 finger LMCS I medial ICS VI
} Auscultation: regular, murmur (-)
} Abdomen:
} Inspection: enlargement (-)
} Palpation: Hepar isn’t palpable, lien S$
} Extremities:
} Oedema pretibia +/+
Laboratory
Hb 6,1 gr/dl
Ht 18 %
WBC 6820/mm3
Diff. Count 0/1/1/48/45/5/
MCV/MCH/MCHC 57/19/33
Ur/Cr 32/0,8
Na/K/Cl 134/3,9/105
Alb/Glob 22/4,5
Rontgen
thorax
Peripheral blood Slide
Ecg
Working Diagnosis
} Moderate anemia normocytic normochrom ec haemolytic
non autoimun ec Thalasemia
} Thalasemia beta mayor
Therapy
} Rest/ Diet High Calori High Protein
} IVFD Nacl 0,9% 8h/kolf
} Ferriprox 3x500mg
Plan
} Transfusion PRC
} Check feritin
4. Friezka, Female, 19 yo, FW16
} Chief Complaint:
} Fatigue and weakness increased since 2 days ago
} Fatigue and weakness increase since 2 days ago
} Fatigue increased since 2 days ago. this complain had been felt
since 1 weeks ago
} Fever (-) Cough (-) Breathlessness (-)
} Decrease of appetite (+)
} Nausea and vomit (-)
} Bloody stool (-)
} Urine was normal
} Patient has known as Thalasemia since 2 years ago and regularly
receive blood transfusion (3-4 times a year)
} History of hypertension and DM type 2 was denied
} General Appearance : Moderate
} BP : 120/83 mmHg
} HR : 110x/minute
} RR : 20x/minute
} T: 36.7º C
} Eye
} conjunctiva anemic (+)
} Icteric sclera(-)
} Neck
} JVP 5-2 cmH20
} Lung:
} Inspection: statically & dynamically symmetric
} Palpation: fremitus right=left
} Percussion: sonor
} Auscultation: vesicular, Rh -/- Wh -/-
} Cor:
} Palpation: ictus is palpated at 1 finger medial
LMCS ICS V
} Percussion:
} Left border: 1 finger LMCS I medial ICS VI
} Auscultation: regular, murmur (-)
} Abdomen:
} Palpation: Hepar isn’t palpable, lien S2
} Extremities:
} Oedema pretibia -/-
Laboratory
Hb 6,1gr/dl
Ht 18 %
WBC 10.270/mm3
Diff. Count 0/5/0/65/26/4
MCV/MCH/MCHC 59/20/33
Ur/Cr 77/2,7
Na/K/Cl 137/3,6/111
Alb/Glob 4,1/3,1
Ferritin 1896
Peripheral blood Slide
Rontgenthorax
Ecg
Working Diagnosis
} Moderate anemia micrositic hypocrom ec haemolytic
non autoimun ec Thalasemia intermediet
} AKI Stage II cb prerenal ec dehidrasi
Therapy
} Rest/ Diet High Calori High Protein
} IVFD Nacl 0,9% 6h/kolf
} Ferriprox 1x750mg
Plan
} Transfusion PRC until Hb > 12 mg/dL
5. Lorenta Nadaek, Female, IW 03, 31 yo
Cc:
◦ Cough since 1 week ago
Present Illness History

◦ Cough (+) since 1 week ago, sputum (+)
◦ Fever (+) since 1 week ago
◦ Fatigue since 3 day ago, look pale (+)
◦ History of bleeding is denied
◦ Decreased urinating since 3 month ago, frec 1-2 times a day, less than half
glass in amount.
◦ There is no Nausea (-) or Vomit (-)
◦ Patien has been known for C K D and routinely undergo hemodialysa for 7
years
Past illness
history
History of hypertension (+), uncontrolled
History of D M (-)
History of cardiac disease (-)
Physical
Examination
Consciousness level:CMC
BP :150/80 mmHg
HR :76 x/minute
RR :28x/minute
T: 36,90 C
Eye
◦ Conjunctiva anemic (+)
◦ Sclera are icteric (-)
Neck
◦ JVP 5-2 cmH2O
Lung:
◦ Inspection: simetric in static and dinamic
◦ Palpation: fremitus equal both lung
◦ Percussion: sonor
◦ Auscultation: Bronchovesicular, Rales(+/+) ,wheezing
(-)
Cor:
◦ Palpation: ictus is palpated at 1 finger lateral LMCS
ICS VI
◦ Percussion:
Left border: 1I finger lateral LMCS ICSVI
◦ Auscultation: Regular, murmur(-), gallop(-)

Abdomen
:
◦ Inspection: enlargement (-)
◦ Palpation: Soepel
◦ Percussion: Tympani
◦ Auscultation: bowel sound (+) normal
Extremities:
◦ Oedema (-/-)
HB/HT/L/Tr 7.6/22/8270/226000
LABORATORY FINDING
PT/APTT 13.3/22.2
Alb/Glb 3.0/3.7
Ur/Cr 103/9.5
Na/K/Cl 133/4.5/104
PH/PCO2/PO2/HCO3-/So2 7.38/25/148/15.8/99
Thorax
ECG
WORKING
DIAGNOSIS
• Community Acquired Pneumonia
• C K D stg V cb hypertensive kidney disease on H D
• Hyperrtensionheartdisease
• Moderate anemia normocyte normochrome cb chronic
Disease
Therapy
Rest/Low Protein diet 50 gr Low Salt II
O2 4L/mnt
IVFD Easpfrimer 500 cc/24 hrs
Inj Ceftriaxon 2x1 gr (iv)
Amlodipine 1x10 mg (PO)
Candesartan 1x16 mg (PO)
Clonidin 3x0.15 mg/PO
Folic acid 1x5 mcg (PO)
Natrium bicarbonate 3x500 mg (PO)
Plan
Culture sputum
Expertised rontgen thorax
Hemodialysis
6. Triana Wahyuni, 30 yo female, HCU
2
Chief Complaint
} Watery stool since 1 week ago
• Watery stool since 1 week. frequention 5 times a day,
amount about 1 glass, blood (-)
• Vomit since 3 days ago. frequention 3x/day,amount about 1
glass.
• Fever since 1 week ago, no chilling
• Decreased of appetite since 1 months ago
• Fatique since 1 week ago, look pale (+)
• Decreased of body weight (-)
• Cough (-), breathlessness (-)
• Micturition was normal
• Patient are known as SLE on therapy.
PAST ILNESS HISTORY :
}History of DM (-)
}History of hypertension (-)
FAMILY HISTORY :
}History of same illness (-)
67
General Examination
} Counsciousness : cmc
} Blood Pressure : 80/64 mmHg
} Heart Rate : 121x/mnt
} Temperature : 38 C
} Respiratory Rate : 24 x/mnt
} Cyanosis :-
} Edema :-
} Anemic :+
} Icteric :-
Skin
Turgor was normal
Lymph nodes
} no enlargement
Neck
Jvp : 5-2cmH2O
Tyroid : not palpable
Head
} Normocephal
}
Eyes
} Anemic (+), icteric (-/-)
Lung:
-Insp : symmetrical static and dynamic
-Palp : fremitus left=right
-Perc : sonor
-Ausc : vesikuler , ronchi -/- , wheezing -/-
Heart
-Insp : ictus unseen
-Palp : ictus 1 finger medial of LMCS RIC V
-Perc : left : 1 finger medial of LMCS RIC V,right :
LSD, upper: RIC II
-Ausc : Iregular rhythm, murmur (-)
Abdomen
-Insp : enlargement of abdomen (-)
-Palp : Liver and spleen unpalpable
-Perc : tympani
-ausc : bowel sound (+) increased
Back
} costovertebral pain (-)
Extremities
Cold akral, Udem -/-
71
Laboratory Values
Hb/ht/leu/Tro 3,8/11/340/6.000
Alb/Glo 2,5/3,9
SGOT/SGPT 222/45
Na/K/Cl 118/3,4/87
Ur/Cr 34/1,3
PT/aptt/d-dimer 11,6/33,2/957
AGD 7,557/16,6/135,7/14,6/-7,2/97,1
Rontgen Thorax
EKG
Working Diagnosis
}Gastroenteritis acute with severe dehydration
} Shock Hypovolemic
}Pansitopenia cb Secondary aplasia
}Febrile neutropenia
}Severe anemia cb Chronic Disease
Therapy
} rest / soft diet low fiber
} Loading Nacl 0,9% 2000 cc à IVFD NaCl 0.9%
6jam/kolf
} IVFD NaCl 3% 500cc 12/kolf
} Inj Ceftriaxone 2x1 gram (iv)
} Inf Levofloxacine 1x500mg (iv)
} New diatab 3 x 2 tab (po)
} Paracetamol 3x500 (po)
} Imuran 2x 50 mg (po)
} Hydroxychloroquine 1x200mg (po)
} Metylprednisolone 1x4 mg (po)
7. Rico Renaldo, Male, 46 yo, HCU
12
Chief Complaint :
} Black stool since 1 day ago
Present Illness History :
} Black stool since 1 day ago, 2-3 times daily, volume around 20
cc/time.
} Black vomit since 1 day ago, 3 times daily, volume around 30 cc.
} Fatigue and weakness since 3 days ago.
} Look pale since 3 days ago.
} There is no fever, no breathlessness, no cough.
} Defecation and micturition is normal.
} Patient was diagnosed by hepatic cirrhosis since 4 month ago.
Pass Illness History :
} History of HT (-)
} History of DM (-)
} History of malignancy (-)
Social and Family History

} There is no family who had same illness
} Consciousness level : Composmentis
} BP : 116/75 mmHg
} HR : 116x/ minute
} RR : 20x/ minute
} T : 36,9
} Sat : 98%
}Skin
Turgor normal
}Lymph nodes
No enlargement on the neck, armpit and thigh area
}Head
Normocephal
} Eye
◦ Conjunctiva anemic +/+
◦ Sclera not icteric
} Neck
◦ JVP 5-2 cmH20
} Lung :
◦ Inspection: normochest
◦ Palpation : simetric dextra and sinistra
◦ Percussion : sonor
◦ Auscultation : vesicular, rhonchi -/-, wheezing -/-
} Cor :
} Inspection : ictus not seen
} Palpation : ictus is palpated at 1 finger medial
LMCS ICS V
} Percussion :
Left border : 1 finger medial LMCS ICS V
Right border : linea sternalis dextra
Upper border : RIC II
} Auscultation : regular, murmur (-)
} Abdomen :
} Palpation : liver unpalpable , spleen s2
} Percussion : tympani
} Auscultation : bowel sound (+) normal
} Extremities :
} Oedema -/-, Palmar eritem (+)
Laboratory
Hb 9,3 g/dL
Ht 26 %
WBC 8.340/ mm3
Platelets 82.000/ mm3
Diff count 0/1/55/32/12
PT/APTT 20/45,4 detik
Alb/ Glb 1,7/3,6 g/ dL
SGOT/ SGPT 52/ 22 U/ L
Bil I/ II 3,5/ 4,6 mg/ dL
Ur/Cr 36/ 0,7 mg/ dL
RBG 111 mg/ dL
Na/K/Cl 137/ 3,6/ 108 mmol/ L
HBsAg/ Anti HCV Non reaktif/ Reaktif
pH/ pCO2/ pO2/ HCO3/ BE/ SO2 7,498/ 18,5/ 121,8/ 14,5/ -9,0/ 98,6
ECG
Chest X-Ray
Working Diagnose
} Hematemesis melena cb variceal bleeding
} Hepatisc cirrhosis post necrotic stadium decompensata
} Mild anemia cb acute bleeding
} Hypocoagulation cb hepatic cirrhosis
} Hepatitis C
Therapy
} Rest/ Liver Diet Via NGT

} IVFD Triofusin : Aminofusin : NaCl 0.9% 1 : 1 : 1 8
hours/kolf
} Bolus Sandostatin 2 amp/IV
} Drip Sandostatin 6 amp in 50cc NaCl 0.9% Via syringe
pump 2,08cc/hours
} Inj Transamin 3x500mg/IV
} Inj Vitamin K 3x10mg/IV
} Lactulac 3x30 mg/PO
Plan
} EGD
8. Murniati, Female, IW 12, 58 yo
Cc:
◦ Fatigue since 3 day ago

◦ Fatigue since 3 day ago, look pale (+)
◦ History of bleeding is denied
◦ Nausea (-), Vomit (-)
◦ Micturition and defecation was normal
◦ Cough (-), Fever (-), Breathlesness (-)
◦ Patien has been hospitalized 1 month ago, get blood
transfution and advice for BMP but refused.
Past illness
history
History of hypertension (-)
History of D M (-)
History of cardiac disease (-)
Physical
Examination
Consciousness level:CMC
BP :130/80 mmHg
HR :86 x/minute
RR :20x/minute
T: 36,90 C
Eye
◦ Conjunctiva anemic (+)
◦ Sclera are icteric (-)
Neck
◦ JVP 5-2 cmH2O
Lung:
◦ Inspection: simetric in static and dinamic
◦ Palpation: fremitus equal both lung
◦ Percussion: sonor
◦ Auscultation: Vesicular, Rales(-/-) ,wheezing
(-)
Cor:
◦ Palpation: ictus is palpated at 1I finger
lateral LMCS ICS VI
◦ Percussion:
Left border: 1I finger lateral LMCS ICS VI
◦ Auscultation: Regular, murmur(+), gallop(-)

Abdomen:
◦ Inspection: enlargement (-)

◦ Palpation: Soepel
◦ Percussion: Tympani
◦ Auscultation: bowel sound (+) normal
Extremities:
◦ Oedema (-/-)
HB/HT/L/Tr 1.7/5/2180/107000
LABORATORY FINDING
PT/APTT 13.8/19.7
Alb/Glb 3.3/3.1
Ur/Cr 71/0.9
SGOT/SGPT 51/29
Thorax
ECG
WORKING
DIAGNOSIS
•Suspect Acute Leukemia

•Severe anemia NN cb Suspect Malignancy
•Anemia heart disease
Therap
y
Rest/Regular diet
IVFD Nacl 0.9% 8jam/kolf
NTR 2x1 tab
Pla
n
Transfusion of PRC
BMP
9. Darmawati, 55 yo, HCU 04
} Cc: Melena since 5 days ago
} Present illness history
} Melena since 5 days ago, frequency 4-5 times per day, about 1
glass per time.
} Cough was denied
} Fever was denied
} Nose bleed (-), gum bleeding (-), easy to bruise (-)
} No swallow at leg nor abdomen
} Breathlessness (-)
} Mictiration like tea colour. (-)
} Sweat at night (-)
} Decreased of body weight (-)
} Past illness history
} Hepatitis (-)
} No history of consume regular medicine
} History of taking chinese medicine (-), herbal (-), and
tradicional medicine (-)
} Family history
} No Family member with the same disease
} Consciousness level : CMC
} BP : 160/70 mmHg
} HR : 82 x/min, regular
} RR : 19 x/min
} T :37,2 ºC
Eyes : konjungtiva anemic (+) , sklera icteric(-),

Lung :
- Insp : symetric, static and dinamic
- Palp : fremitus dextra = sinistra
- Perc : sonor
- Ausk : vescicular, rhales (-/-), wheezing (-)
Heart
} Inspection: ictus is not seen
} Palpation: ictus palpated at 1 finger lateral LMCS ICS V

} Percussion:
} Left border: 1 finger lateral LMCS ICS V;
} Right border: LSD;
} Auscultation: regular rhythm, murmur (-)
Abdomen
- Insp : enlargement of abdomen (-), venectasi (-)
- palp : liver and lien are unpalpated
- Perc : timpany. shifting dullness (-)
- ausc : bowel sound (+) N
Extremities : oedem (-/-), Physiologycal reflex (+/+),
pathological reflex (-/-), erytem of palmar (-)
Laboratory Findings
Hb 9,5 PT 12,2 s
Ht 15,73 APTT 47,0 s
L 13.512 SGOT 912
Tr 37.000 SGPT 527
Diff count 0/0/1/73/21/5 Alb/glob 3,7/2,0
Ur/kr 35/0,7 RBG 149
Na/K/Cl 143/3,5/109
X Ray
ECG
Working Diagnose
} Melena ec peptic ulcer
} Mild Anemia normocytic normochrome cb acute bleeding
} Type 2 DM uncontrolled overweight
} Hypertension stage 2 cb essential
} Urinary tract infection
Theraphy
} Rest/ flow NGT, fasting/ O2 3 liter/minute
} IVFD aminofusin: triofusin : NaCl 0,9% 1:1: 2 6 hours/kolf
} Inj lansoprazole 60 mg followed with 30 mg in 100 cc
NaCl 0,9% in 1 hour every 6 hours
} Inj Vit K 3x1 amp
} Inj Transamin 3 x 1 amp
} Inj Ceftriaxone 2 x 1 gram
} Amlodipin 1x5mg
} Candesartan 1x8 mg
} Fluid balace: balance
Plan
} Urinalysis
} Culture urine
} EGD
10. Aisah, female, 61 y.o, FW 12
} Cc:
} Breathlessness increased since 3 days ago.
} Breathlesness increased since 3 days ago. Breathlessness has been
felt since 3 months a go, affected by activity, not affected by food or
weather.
} Waist pain since 3 months a go
} Hematuri since 3 months a go, not always
} Abdominal enlargement since 1 month ago
} Look pallor since 1 weeks a go
} Fatigue and weakness that increased since 3 days a go, fatigue and
weakness has been felt since 1 weeks a go
} Fever (-)
} Cough (-)
} Spontaneus bleeding (-)
} History of hipertension (-)
} History of DM (-)
} BP : 80/70 mmHg
} HR : 120x/minute
} RR : 26 x/minute
} T: 37 C
} Spo2 93%
} Eye
} Conjunctiva are anemic (+)
} Sclera are icteric (-)
} Neck
} JVP 5-2cmH20
} Lung:
} Inspection: simetric at statis and dinamic
} Palpation: fremitus Right = Left
} Percussion: : sonor
} Auscultation : Pulmo sinistra : vesikuler, ronki (+/+), wheezing (-
/-)
} Cor:
} Inspection: ictus isn’t seen
} Palpation: ictus palpable 1 finger medial LMCS ICS V
} Percussion:
} Left border: ICTUS palpable 1 finger medial LMCS ICS V
} Right border: LSD
} Upper border: RIC II
} Auscultation: pure rhythm, murmur (-)
} Abdomen:
} Palpation: liver and spleen hard to access
} Percussion: shifting dulness +
} Extremities:
} Oedema -/-
X-Ray
ECG
Laboratory
Hb 6.4 gr/dl
HT 19 %
WBC 13070
Platelet 444.000
DC 0/0/91/3/6
PT/APTT 10.2/18.7
Alb/glo 2.6/2.8
OT/PT 15/7
Ur/Cr 240/2,5
RBG 113
Na/K/Cl 131/4.0/88
BGA 7.54/27.7/144.7/24.3/2.5/97.9
eGFR 20-23
Working Diagnose
} Septic shock cb Hospitalized acquired pneumonia
} Acute on CKD
} Moderate Anemia normositik normokrom cb chronic
desease
} Susp Tumor intra abdomen
Therapy
} Rest/ soft diet/o2 3l
} Loading Nacl 1000cc then drip vascon 1 amp
} Cefepim 3x1g IV
} Levofloxasin 1x500mg IV
} Sodium Bicarbonate 3x500 mg
} Folic acid 1x 5 mg
} N-acetilsistein 3x200mg
} Fluid Balance (+)
Plan
} Tranfusion PRC
} USG abdomen
} Experise chest x ray
} Hepatitis marker
11. Ermanita, female, 47th YO, HCU 03
} CC:
Breathlessness (+) since 2 days ago
} Breathlessness (+) since 2 days ago,
continuously, unaffected by weather, food and activity
} Fever (+) since 2 days ago, not high, no chills
} Black vomit since 2 days ago
} cough (-)
} Decrease of consciousness since 9 days ago suddenly,
Patient has been hospitalized for brain bleeding in
neurology department.
} Weakness of right extremities since 9 days ago
} Defecation and micturition within normal limits
} History of swollen leg was denied
} History of breathlessness was denied, history of
breathlessness after walking distance was denied
} History of Hypertension (+) since 2017.
} History of DM (+) type 2 since 2017 and get insulin
theraphy.
level of consciousness : sopor
General circumstances : severe
BP : 127/77 mmHg
HR : 112 x/minute
RR : 29x/minute
T: 38oC
SpO2 = 99%
Eye
◦ Conjunctiva anemic -/-
◦ Sclera icteric -/-
Neck
◦ normal
◦ Thorax : normochest
Lung:
◦ Inspection : Simetric left = right,
◦ Palpation : fremitus could not be assesed
◦ Percussion : sonor
◦ Auscultation : Broncovesicular, Rh +/+ Wh -/-
Cor:
◦ Inspection: ictus is seen at ICS VI
◦ Palpation: ictus is palpated at 1 finger lateral LMCS
ICS VI
◦ Percussion:
Left border: 1 finger lateral LMCS ICS VI
◦ Auscultation: murmur (-)
Abdomen:
◦ Inspection : Enlargement (-)
◦ Palpation : Hepar not palpable and lien
not palpable
◦ Percussion : thympani, shifting dullness (-)
◦ Auscultation : bowel sound (+) normal
Extremities:
◦ Physiologic Reflex +/+
◦ Pathologic Reflex -/-
◦ Oedema -/-
Laboratory
Examination Result
Hb 10,3
Leucocyte 14.450
platelet 213.000
Hematocrit 34%
Diff Count 0/2/1/62/26/9
Alb / glob 3,7/4,2
procalcitonin 1,31
Ur/Cr 131/3,2
SGOT/SGPT 26/16
Na/K/Cl 140/4.5/112
PT/APTT 9,7/18,7
31/03/21
Laboratory
Examination Result
BGA 7,38/24/109/14,2/98%
HDL/LDL 25/160
Trigliserida 290
total cholesterol 263
Uric acid 10,3
RBG 189
Hba1C 10,2
31/03/21
ECG
Ro Thoraks
CT scan of brain
Working Diagnose
} Sepsis ec Hospital Acquired Pnemonia
} Hemathemesis cb stress ulcer
} DM type 2 uncontrolled overweight
} Acute on CKD
} Ischaemic Miokard of inferolateral
} Dyslipidemia
} Hyperuricemia
} Stroke hemorrhagic e/r thalamus (s) +
intraventricular OH-9
Therapy
Rest/ fasting for 8 hours continue with liquid diet 6X150cc Heart diet, diabetic diet
1700 kkal via NGT,
IVFD Nacl 0,9% 8 hours/kolf
Inf levofloxacin 1x250mg IV
Inj meropenem 2x1gr IV
Bolus prosogan 2 amp (extra)
Drip prosogan 4x1 amp in 100 cc Nacl 0,9% finished in 1 hour
Vitamin K 3x1 IV
Transamin inj 3x1 IV
Novorapid 3x8 unit (correction dose) SC
Levemir 1x18 unit SC
Paracetamol 2x500 mg PO
Candesartan 1 x 16 mg PO
Amlodipin 1 x 10 mg PO
Atorvastatin 1x40 mg PO
Allopurinol 1x100 mg PO
Asetil sistein 3x200 mg PO
Planning
} Sputum, blood, urine culture
} Check GDP, GD2PP
} Urinalysis
12. lisdawati, female, 67 yo, HCU 10
Cc:
◦ Decrease of consciousness since 1 day ago

◦ Decrease of consciousness since 1 day ago slowly until the
patient could not communicate. Patient look sleepy since 3
days ago.
◦ Decrease of appetite since 2 weeks ago
◦ Nausea (+) but no vomitting since 1 week ago
Cough (+) and breathlessness (+) since 3 days ago,
continuously, unaffected by weather, food and activity
◦ Fever was denied
◦ Urination was normal
◦ Defecation was normal
Past Illness History
} History of Hipertension (+) since 2 years ago not
routinely controlled
} History of DM (-)
} History of heart disease (-)
Family Illness History

} There is no family with the same illness
General appearance: Severe
Consciousness level: Apatis
BP : 101/66 mmHg
HR : 99x/minute
RR : 24x/minute
T. : 37,50 C
Skin
turgor was normal
Limph Gland
No enlargement
Eye
} Conjunctiva are anemic -/-
} Sclera are icteric -/-
Neck
} JVP 5-2 cmH20
Lung
} Inspection: simetric in static and dinamic
} Palpation: fremitus could not be assesed
} Percussion: sonor
} Auscultation: bronchovesicular, Rales +/+, wheezing -/-
Cor
◦ Inspection: ictus is seen at ICS V
◦ Palpation: ictus is palpated at 1 finger medial LMCS ICS V
◦ Percussion:
Left border: 1 finger lateral LMCS ICS V
◦ Auscultation: murmur (-)

Abdomen:
} Palpation: hepar and lien not palpable
} Percussion: tymphani, shifting dullness (-)
Extremities:
} Edema -/-
RT: melena positive

Laboratory Findings
Hb 9,9 g/dL
Ht 34%
leucosite 35.920/mm3
DC 0/0/8/80/8/2
Ur/ cr 26/1,9 mg/dl

Na/K/Cl 131/3,4/94
PT/APTT/Ddimer 17,7/38,5/3561
Albumin/Globulin 2,1/3,6 g/dl
PH/ pCO2/pO2/HCO3-/SO2 7,48/15,8/26,3/12/57,4
SGOT/SGPT 133/50
RBG 60
ECG
X-ray
Working Diagnose
} Decrease of consciousness cb hypoglikemia

} Sepsis ec hospital acquired pneumonia with respiratory
failure type 1
} Melena cb susp ulcus pepticum
} AKI stage 1 cb pre renal cb sepsis
} Mild anemia normocytic normochrome cb acute bleeding
} Sugestive DIC ec Sepsis
} Hypoalbuminemia
} Old MCI
DIFFERENTIAL Diagnose
- Decrease of conciousness cb hypoxemia

- Decrease of conciousness cb sepsis associated
encephalopaty
Therapy
} Rest/ 6x100 cc liquid food diet via NGT / O2 12 lpm via NRM
} Hypoglicemia protocol
Inject d40% 50cc, every 15 minutes until blood glucose above 100, and
patient awaked
IVFD D10% 8hrs/kolf
} Inj cefepime 3x1 gr iv
} Inf Levofloxacine 1x750 mg iv
} Bolus prosogan 2 amp (extra)
} Drip prosogan 4x1 amp in 100 cc Nacl 0,9% finished in 1 hour
} Albumin transfusion 20%
} Inj vit K 3 x 1 amp (IV)
} Inj transamin 3 x 1 amp (IV)
} Acetylcisteine 3x200 mg po
} Paracetamol 3x500 mg po
} Sukralfat 3 x 10 cc
} Fluid balance
plan
} Urinalysis
} Complete blood count
} Sputum Culture, blood culture
} EGD
13. Eka Prima Susilawati , 34 yo, FW 17
} Cc: Gum bleeding since 3 days ago

} Gum bleeding since 3 days ago, frequency 2-3 times per day, about ± ¼ portion of spoon
} History of skin bruises since 2 months ago
} Swollen at gum since 1 months ago, pain (-)
} Fatique since 2 weeks ago
} Deacreased of appatite since 1 weeks ago
} Paleness (-)
} Fever (-)
} Cough (-)
} Vomite and nausea (-)
} Patient has been known as AML since 1 weeks ago and be scheduled to chemotherapy
} BP : 110/70 mmHg
} HR : 80x/minute
} RR : 18 x/minute
} T : 36,7 C
} Eye
} Conjunctiva are anemic +
} Sclera are icteric -
} Neck
} JVP 5 -2 cmH20
} Mouth : petekie (+) at buckal;

} Gum: swollen (+), reddish (-), pain +
} Lung:
} Inspection: simetric static and dinamic
} Palpation: fremitus right = left
} Percussion: sonor
} Auscultation: vesicular, rales -/-, wheezing (-/-)
} Cor:
} Palpation: ictus is not palpable
} Percussion:
} Right border: LSD
} Auscultation: normal (+)
} Abdomen:
} Palpation: liver and spleen are not palpable
} Percussion: shifting dullness (-)
} Extremities:
} Oedema -/-, FR (+/+), Pr (-/-)
Laboratory
Hb 7,6 gr/dl
Ht 22 %
WBC 3.940/mm3
Platelet 46.000 /mm3
RBG 110 mg/dl
Ur/ Cr 13/0,7 mg/dl

Natrium 129 Mmol/L
Kalium 2,5 Mmol/L
Clorida 86 Mmol/L
SGOT/ SGPT 14/36 mg/ dl
PT/ APTT 12,4/21,9detik

Ro thorax
Diagnose
} Diathesis haemorhagic ec trombositopenia ec AML

M5
} AML M5 pro chemotherapy
} Moderate anemia normocytic normocrom ec
malignancy
} Trombocytopenia ec malignancy
} Candidiasis oral
} Hypokalemia
Therapy :
- Rest/ Soft diet 2100 kkal
- IVFD NaCl 0,9% 8hours/kolf
- Inj ceftriaxone 2x1 gr
- Paracetamol 3x500 mg
- Nystatin drop 4x1 gtt
- Fluconazole 1x200 mg
- KSR 2x1 tab
- Transamin 3x500mg IV
- Transfusion PRC 1 Unit/day
planning
} Transfusion PRC until HB >=10
} Chemotherapy
14. Elliwida 60 y.o, Female, FW 21
CC:
q Melena since 1 week ago
Present Illness History:

} Melena since 1 weeks ago, about ¼ of glasess, consistency normal.
} Patient has been using aspilet since 1 months ago.
} Abdominal pain increased since 1 week ago, has felt 1 month ago, come and go, reffered to
backpain and chest area (-).
} Patient was breathlessness (-), cough (-)
} Chest pain (-)
} Patient has been known as Hypertension and diabetic since 4 years, and controlled
} Micturition was normal
History past illness
} History of DM : + since 4 years ago, get routine therapy basal insulin and long acting insulin.
Absent since 3 mounth ago.
} Hitory of hipertension (+) since 4 years ago.
} BP : 150/70 mmHg
} HR :82x/min
} RR : 20x/minute
} T: 36,6 oC
} Skin : ptechie (-)
} Eye
} Conjunctiva anemic (+/+)
} Sclera icteric (-)
} Neck
} JVP 5-2 cmH20
} Lung:
} Inspection: symetric left=right
} Palpation: fremitus left=right
} Percussion: sonor
} Auscultation:vesicular, rales -/- wheezing -/-
} Cor:
} Palpation: ictus is not palpable
} Percussion:
} Right border: LSD
} Auscultation: normal (+)
} Abdomen:
} Palpation: liver and spleen are not palpable
} Percussion: shifting dullness (-)
} Extremities:
} Oedema -/-, FR (+/+), Pr (-/-)
Laboratory
Laboratory Result
Hb 9,3 mg/dl
Ht 28 %
WBC 13640 mg/dl
Platelet 885.000 /mm3
BGR 126 mg/dl
Ur/cr 13/ 0,8 mg/dl
Na / K / Cl / Ca 141/4,8/111
SGOT/ SGPT 47/31
Alb/glb 3,1/3,1
Ro Thorax
ECG
Working Diagnose
} Melena c.b gastropati NSAID
} Essential trombocytosis
dd/ Reactive trombocytosis
} Tipe 2 DM controlled insulin normoweight
} Mild anemia normocytic normochrom cb chronic
disease
} Myocard ischemic anteroinferior
} Hypoalbuminemia
Therapy
} Rest/ Diabetic Diet low salt 1700 kkal
} Ivfd nacl 0.9% 8 h/kolf
} Bolus prosogan 2 amp iv
} Drip prosogan 1 amp / 100cc Nacl 0,9% for 1hours 4x1 iv
} Inj.Vitamin K 3x1amp iv
} Inj. Transamin 3x500mg iv
} Novorapid 3x14 iu sc
} Levemir 1 x 16 iu sc
} Domperidone 3x10 mg po
} Paracetamol 3x500 mg po
} Candesartan 1x 16 mg po
} Amlodipin 1x10 mg po
} Vitamin b complex 1x1
} Plan :
} check troponin I
} EGD

Lapjag 30 Maret

Uploaded by

Copyright:

Available Formats

Lapjag 30 Maret

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lapjag 30 Maret

Uploaded by

Copyright:

Available Formats

Morning Report

March 30, 2021

• Family Illness History

◦ Palpation: ictus is palpated at LMCS ICS VI

 Right border: linea sternalis dextra

 Upper border: RIC II

◦ Auscultation: pure rhythm, no murmur,

} Consciousness level: CMC

} Consciousness level: CMC

Present Illness History

Right border: linea sternalis dextra

Upper border: RIC II

◦ Auscultation: Regular, murmur(-), gallop(-)

Social and Family History

} Rest/ Liver Diet Via NGT

Present Illness History

Right border: linea sternalis dextra

Upper border: RIC II

◦ Auscultation: Regular, murmur(+), gallop(-)

◦ Inspection: enlargement (-)

•Suspect Acute Leukemia

Eyes : konjungtiva anemic (+) , sklera icteric(-),

} Palpation: ictus palpated at 1 finger lateral LMCS ICS V

Present Illness History

Family Illness History

General appearance: Severe

Consciousness level: Apatis

} Auscultation: bronchovesicular, Rales +/+, wheezing -/-

◦ Auscultation: murmur (-)

RT: melena positive

Ur/ cr 26/1,9 mg/dl

} Decrease of consciousness cb hypoglikemia

- Decrease of conciousness cb hypoxemia

} Present Illness History

} Mouth : petekie (+) at buckal;

RBG 110 mg/dl

Ur/ Cr 13/0,7 mg/dl

PT/ APTT 12,4/21,9detik

} Diathesis haemorhagic ec trombositopenia ec AML

Present Illness History:

History past illness

You might also like

Right border: linea sternalis dextra

Upper border: RIC II