MORNING REPORT

JULY 21ST 2014

PATIENT IDENTITY
Name

: Mr. J

Age

: 42 yo

Address

: solo

Adimmted

: july 21st, 2014

MR

: 01191137

Ward

: Melati 1/ 2D

ANAMNESIS
Chief complain : consciousness
Present Ilness :
Since 1 hour before admission patient got consciousness. He cant
communicate well, He can open her eyes when her name called, but he back
asleep again. There is no history of trauma or seizures before and is not
accompanied by chest pain.Loss of consciousness accompanied by weakness
The patient complained of weakness since 3 days ago. Weakness
continuously so that the patient can not be activity and keep when standing.
Weakness doesnt improve with feeding and drinking. Weakness is not
accompanied by vomiting, no accompanied with blackish spots appear on the
skin and is not accompanied by liquid defecation. Defecation once a day, there is
no blood. Urinate is reduced 2-3 times a day @ 1/2 glasses. previously patients
stop injecting insulin because it feels the pain

2 Past History Disease

Time

Place of admission

History of Therapy or
treatment

2012

RSDM

DM tipe 2
Use insulin rapid 10-10-10

3 Family History Disease

Diabetes mellitus : denied
Hypertension : denied

Physical Examination
General Appearance:
Apatis , E4 V4 M5

Vital Sign:
T
N
R
S
BB
TB
BMI

:
:
:
:
:
:
:

120/70 mmHg
108x/menit
24 x/menit
36 oC (aksiler)
60 kg
160 cm
23 kg/m2

Physical Examination

Anterior Chest:
I.

Chest expansion right=left

P.

Grobe fremitus right=left

P:

sonor/sonor

SDV (+/+), RBK(-/-)

Abdomen
I : DP //DD, venektasi (-)
A :Peristaltik (+) N
P :tympani, area troube tympani
P. supel, hepar/lien not palpable

Oedem eyelid --/Pale conjunctiva (-/-)

Sklera ikterik -/Papil lidah atrofi (-)
JVP R+2 cm, enlargement
lymponodi (-)
Cor:
I. IC not seen
P. IC not palpable
P. Cardiac border not widened
A. 1st and 2nd heart sound
increase, regular,
murmur (-)

Oedem superior -/Oedem inferior -/-

5 Laboratory Examination
21/7/2014

satuan

Hemoglobin

15,1

g/dl

Eritrosit

4,5

106/ul

Hematokrit

41

Lekosit

6,1

Trombosit

Date

Nilai rujukan

13,5 -

17,5

4,50
5,90
33

103/ul

4,5

11

271

103/ul

150 450

Ureum

59

Mg/dl

10

50

Creatinin

0,6

Mg/dl

0,6

1,1

SGOT

13

u/l

0-35

SGPT

25

u/l

0-45

Natrium

133

Mmol/L

Kalium

4,0

Mmol/L

Clorida

100

Mmol/L

HbsAg

nonreaktiv

GDS

428

Mg/dL

45

136 145
3,3

5,1

98-106

5 Laboratory Examination

Asidosis metabolic partial

compansated

6 DIAGNOSIS
1.

DM tipe 2 non obese with Ketoasidosis Diabeticum

2.

Mild hiponatremia

Planning therapy

1. Totally bedrest
2. 02 3 lpm

3. DM diet 30kal/kgbb/day-10% (1700 kal/day) personde

4. Rehidration: Hr I NaCl 0,9% 1L
Hr II NaCl 0,9% 1L
Hr III NaCl 0,9% 500 cc
Hr IV NaCl 0,9% 500 cc
Hr V NaCl 0,9% 500 cc
Hr VI NaCl 0,9% 200 cc

Bolus insulin 8 unit iv GDS : 335

Continuous Insulin rapid 6 iu/hr

- if blood glucose decrease < 10 % increase 1-2 unit insulin/hour
- if blood glucose decrease > 10 % continue dose
- if blood glucose decrease < 180 stop insulin in 1 hr

after blood glucose < 100, change fluid with D10% 20 tpm,

7. Inf KCl 20 mEq/L

8. Inj. Ceftriaxon 2 g/24 hr

Planning Diagnosed
1. Profil lipid, funduscopy,monofilamen
2. GDP, GD2PP, HbA1C if clinically release

Planning education

1. Give explanation to her family about the patients condition, disease,

how to treatment, and complication

Planning Monitoring
1. GCS, vital sign, blood glucose/ hour
2. fluid balance/4 hour
3. BGA 6 hour post correction
4. Kalium

jam

GCS

Vital sign

GDS

01.00

E4 V4 M5

110/70, 84x, 24x, 36,4 C

334

SP 6 iu/hr

02.00

E4 V4 M5

110/70, 88x, 24x, 36,4 C

404

SP 6 iu/hr

03.00

E4 V4 M5

110/70, 84x, 20x, 36,4 C

356

SP 6 iu/hr

04.00

E4 V4 M5

110/70, 80x, 20x, 36,4 C

315

SP 6 iu/hr

05.00

E4 V4 M5

110/70, 84x, 20x, 36,6 C

248

SP 6 iu/hr

06.00

E4 V4 M5

110/70, 84x, 20x, 36,7 C

188

SP 6 iu/hr

jam

urin

06.00

1500 cc

Insulin

TERIMA KASIH