MORNING REPORT

Sunday 13th November 2016

Coass in Charge:
1.

Supervisor
dr. Syifa Mustika, Sp.PD
 SUMMARY OF DATABASE
Mrs. S/51 YO/W.28
History Taking :
Chief Complaint: shortness of breath
History of Present Illness : autoanamnesa
Patient suffered from shortness of breath since 1 week ago. The
shortness of breath worsening 1 day before admission. Since 1
week before admission, worsen by activity and better when rest.
The shortness of breath happens about 5 minutes. Her felt
shortness of breath when she walk about 100 m or doing heavy
activity better when rest. She can sleep well but need more than
1 pillow.
Patient also complained abdominal pain since 2 days before
admission. It occurred gradually onset and didnt radiated to
back and didnt affected by meal.
The patient also felt nausea without vomiting since 1 week
before admission. She feels pain at the left upper quadrant.
Passing stool and passing urine were normal.
She was diagnosed problem tyroid since 22 years ago.
Sometime felt pain at the nodule. Patient routinely go to
endocrine out patient clinic cause of tyroid problem and got
Past Medical History :
No past medical history

Family History :
There was no family member who suffered with same
illness and disease.

Social History :
She has widow and had two children. She lived with her
brother.

History of Allergy :
There was no allergic history of food nor any medication.
Physical examination
General appearance looked moderately ill GCS 456

BP = 110/80 mmHg PR = 104 in ER92 in ward RR = 24 tpm Tax : 36.5 C

bpm, regular strong

Head Pale conjunctiva -

Icteric Sclerae -

Neck JVP R + 0 cmH2O 30 degree

Tyroid : palpaple mass with diameter about 5 cm, mobile, painless, bruit(-)
Chest Heart: Ictus invisible and palpable MCS ICS V
LHM ~ ictus
RHM ~ SL D
S1 S2 single, murmur (-), gallop (-)

Lung: Chest percussion: s I s Auscultation: Ronchi - I - Wheezing - I -

sIs -I- +I+
sIs -I- +I +

Abdomen Flat, bowel sound (+) normal, liver span 8 cm, Traubes space tympany, soefl, shifting
dullness -

Extremities Oedema -/- , warm acral

 LABORATORIUM FINDING
Hb 12.4 g/dL 11.4-15.1 Ureum 16.5 16.6-48.5
g/dl mg/dL
80-93 f
27-31 pg
Leukocyte 20.680 uL 4.7-11.3 Creatinine 1.16 <1.2
103/uL mg/dL
Thrombocy 349 103/uL 142-424 Natrium 140 136-145
te 103/uL mmol/L
Hematocrit 37.6 38-42 % Kalium 4.36 3.5-5.0
mmol/L
Diff count 1.8/0.2/89. 0-4/0-1/51- Chloride 107 98-106
5/4.2/4.3 67/25-33/2- mmol/L
5
SGOT 118 0-32 u/L RBG 104 < 200
mg/dL
SGPT 65 0-33 u/L albumin 3.86 3.5-5.0
g/dL

Calcium 9.0 7.6 11

mg/dL
Phosphor 6.4 2.7 4.5
 Urinalysis
Lab Value Lab Value
Urinalysis 10 x

SG 1,020 Epithelia 2.3

PH 5.5 Cylinder -
Negatif Hyaline
1-2
Leucocyte
Nitrite Negatif Granular -

Protein 2+ Leukocyte -

Glucose Negatif Erythrocyte -

Erythrocyte Negatif 40 x
Erythrocyte 2.6
Keton urine - Eumorfik -
Urobilinogen - Leukocyte 9.5
Bilirubin - Crystal -
Bacteria 5016 x 103 /mL
 BLOOD GAS ANALYSIS
(November 12nd )
BGA Value Normal Value
With 02 8 lpm
supplementation
PH 7.22 7,35-7,45
PCO2 38.1 35-45 mmHg
PO2 54.7 80-100 mmHg
HCO3 15.6 21-28 mmol/L
Base Excess -12.4 -3 until +3
mmol/L
O2 saturation 85.6% > 95%

Conclusion Acidosis Metabolic Uncompensated

CXR
ECG
 FNAB
Adenomatous goiter with nodul
hyperplastic
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs.S./51 1. 1. COPD on Echocar Inj.Methilprednisolon Subjec
YO/W.28 Short treatme diograp 3x62.5mg (iv) tiVS,
AX: ness nt hy Nebul Combivent/ 8 FT4,
SOB since 1 of 2. HF stage hours TSH
week breath C FC III
Had diagnosed 2.1 Tyroid
tyroid problem heart
(+) disease
DOE (+), PND
(-)
Routine
controlled to
pulmonology
outpatient clinic
because COPD
PE :
BP :
110/80mmHg
HR : 92 bpm
Pulmo :
Wheezing +/+
ECG :
sinus rhytm
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs.S./51 2. Peroral : Subjec
YO/W.28 Goiter Thyrozol 1x 20mg tiVS,
AX: adeno Propranolol : FT4,
matos 2x10mg TSH
Had lump at the a
neck since 22 Pmon
years become :
bigger gradually BW
score
PE :
BP :
110/80mmHg
HR : 92x/mnt

Thyroid : palpaple
mass dimeter about
5 cm, mobile,
painless, bruit(-)
BW score : 15 at ER
10 at ward

FNAB :
Adenomatous
goiter with
nodul
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs.S./51 YO/W.28 3.Leuc 2.1 Urinalys Confirm diagnosed Subjec
ositosi Infection is tiVS,
Lab : s 2.2 infuse Ciprofoxacin CBC /
Leucocyte : Blood
Reactive 2x400mg (IV) 3 days
culture
20680 microliter
and
sensitivi
ty test
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs.S./51 4.Incr 4.1 drug HbsAg, Confirmed Subjec
YO/W.28 ease induce Anti diagnosed tive,
of 4.2 HCV VS
Lab : Transa Reactive
SGOT :118 U/L minas
SGPT :65 U/L e
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs.S./51 4.Hipe Confirmed Subjec
YO/W.28 rfosfat diagnosed tive,
emia Peroral : VS,
Lab : CaCO3 3x 500mg SE/3
Phospor : 6.4 days
mg/dL
 CUE AND CLUE PL Idx PDx PTx PMo
Mrs. S/51 5. 5.1 Soft diet High Subjecti
YO/W.28 Dyspep Gastritis calory high protein ve, Vital
AX: sia Errosive 1,700 kcal/day Sign,
Nausea without Syndro 5.2 PUD Inj Lansoprazole Nausea
vomiting me 1x30 mg IV

PEd :
Disease,
underlyin
g
disease,
treatmen
t,
prognosis
 Condition this
GCS : 456
morning
BP : 120/70 mmHg
HR : 84 bpm
RR : 20 tpm
Tax : 36.6oC
UOP : 40 cc/hour
RBS : 134 gr/dL
Thank You