MORNING REPORT

dr. Febri

Wednesday, October 5th 2016

PHYSICIAN INCHARGE:
I : dr. Febri, dr. Tio, dr. Ari
II CVCU: dr. Nudi
II HCU : dr. Yuni
II UGD : dr. Indra, dr. Bayu
Chief Jaga : dr. Ramadhan
Konsultan Jaga: dr. Dewi Indiastari, Sp.PD

MODERATOR: dr. B.P. Putra Suryana, Sp.PD-KR

 Summary of Data Base

Mrs. Soedjinah/80 yo/w.24a

Chief complaint: diarrhea

Heteroanamnesa with her daughter

Patient suffered from diarrhea since 12 hours before admission. Diarrhea more than 6
times/day, fluid dominant, greenish colour, mucous (+), blood (-). She also felt abdominal
discomfort, often felt fullness of her stomach. She usually passed stool every 4-5 days. Since 3
years ago, she passed stool in small volume then she took dulcolax to increase volume of stool.
But, she didn’t take dulcolax since 2 months ago.

She felt itchy at her abdomen since 1 month ago then she scratched it that caused redness at
her skin. At first, the redness size was small but it grow bigger.

She fell 3 years ago that broke her right upper leg. Because of this, her daily activity was helped
by her daughter especially when she took a bath.
History of present ilness

Hypertension since 10 years ago but she didn’t take medicine regularly.

Dyspepsi syndrome since she was young. She took antasida to relieve ths symptom.

History of medication

She didn’t take any medicine

History of family:

No family that had same illness with her.

History of privation and social:

She is a widowes, had 5 children.

 Physical examination
General appearance looked moderately ill GCS 456
BP = 150/90 mmHg HR = 80 x/m RR = 20 tpm Tax = 36,3 °C
Head Anemic conjungtiva (-) Sclera icteric (-) dry mucous of the mouth (+)
Turgor decreased at glabella
Neck JVP R + 2 cm position 30°,
Thorax: Cor: Invisible and palpable at ICS VI MCL S
RHM SL sinistra
LHM ≈ ictus
S1, S2 single with no murmur
Lung: Symmetric, SF D = S v v Rh - - Wh - -
v v - - --
v v - - --
Abdomen Soefl, BS + increase, liverspan 8cm, traube’s space tympani, shifting
dullness (-)
Skin lesion,macula hiperpgmentation, polycylic form, redness, clear
border, squama +, central healing +
Extremities Warm, extremity edema -/- , alligment deformity (-)
-/-
 LABORATORY FINDING
Lab Value (Normal) Lab Value (Normal)
Leucocyte 25,300 4.700 – 11.300 Natrium 133 136-145 mmol/L
/µL
Haemoglobine 16.1 11,4 - 15,1 g/dl Kalium 4.38 3,5-5,0 mmol/L
PCV 48.3 38 - 42% Chlorida 107 98-106 mmol/L
Trombocyte 397,000 142.000 – Ureum 59.5 20-40 mg/dL
424.000 /µL
MCV 87.1 80-93 fl Creatinine 0.86 <1,2 mg/dL
MCH 29.3 27-31 pg BUN/Cr 32.32
Eo/Bas/Neu/limf/ 0/0.2/91.6/3.4/ 0-4/0-1/51- eGFR 32.9
Mon 4.8 67/25-33/2-5
SGOT 34 0-32 mU/dL Albumin 3.4 3.5-5.5 g/dL
SGPT 12 0-33 mU/dL RBS 125 mg/dL
CXR
 CXR

• AP position, asymmetric, KV strong, lessinspiration

• Soft tissue thick, bone normal
• Trachea deviation to the right at vertebra I-V
• Right and left hemidiaphragm were dome shape
• Costo phrenico angle d/s were sharp
Lung:
• Right lung: bronchovesicular pattern normal
• Left lung: bronchovesicular pattern normal
Cor:
• site normal, size 55% apex embedded, cardiac waist (+)

Conclusion : dense at suprahiler left pulmo, suspect mediastinum

mass
BoF
Dilatation of small and large
bowel with fecal material
prominent

Conclusion:
• Meteorismus
ECG
 ECG
 Sinus rhythm Heart rate 75 bpm
 Frontal Axis : LAD
 Horizontal Axis : normal
 PR interval : 0,12”
 QRS complex : 0,08”
 QT interval : 0,40”
 Inverted T wave at lead V1-V6
 Conclusion : Sinus rhythm Heart rate 75bpm, suggest ischemia
anterior extensive
 The Barthel Index

0
3

0
3

1
0

1
0

2
0
10
Mini Nutrition
2 Assesment
3

12
The Geriatric Depression Scale

score
1 0 11 0 21 0
2 0 12 0 22 0
3 0 13 0 23 0
4 0 14 0 24 0
5 0 15 0 25 0
6 0 16 0 26 0

7 0 17 0 27 0
8 0 18 0 28 0
9 0 19 0 29 0
10 0 20 0 30 0

Total Score

Can’t be evaluated
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mrs. 1.Acute 1.1 related Fecal Bed rest Diarrhea
Soedjinah/80yo/w.24a inflamatory infection analysis BP, HR, RR,
diarea + 1.1.1. EIEC Soft diet 1700 kcal/day, low Tax,
Anamnesa moderate 1.1.2 EHEC Fecal fiber, high protein Urine
diarrhea since 12 hours dehydration 1.1.3 culture production
before admission, more shigelosis and Rehydration NaCl 0,9% 1000
than 6 times/day, fluid 1.1.4 sensitivity cc – continued with NaCl 0,9% Education:
dominant, greenish salmonella test 20 tpm Soft diet
colour, mucous (+), blood
(-). 1.2. Inf ciprofloxacin 2x400 mg
felt abdominal discomfort, malignancy
1.2.1 Po Attapulgite 2tab/ diarrhea
Physical Examination Colorectal (maximal 10 tab / day)
BP = 150/90 mmHg Ca?
Tax = 36,3 °C

Dry mucouse of the

mouth
Bowel sound increase
Decreased turgor

Lab
Diff count:
Neutrofil 91.6%
Leucocyte 25.300/uL
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mrs. Soedjinah/80yo/w.24a 2. 2.1 dt no 1 As above Monitornig:
Leukositosis CBC every 3
Lab: WBC: 25,300/uL 2.2 reactive days

Mrs. Soedjinah/80yo/w.24a 3. Tinea KOH Cetirizin 1x1 tab Monitornig:

corporis staining Flukonazole 1x1 tab Itchy
Anamnesa
Felt itchy at abdomen since Pedu:
1 month ago at her skin. At hygiene
first, the redness size was
small but it grow bigger.

Physical Examination
Skin lesion, redness, clear
border, squama +
Macula
hiperpigmentation,central
healing, polycyclic form
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mrs. Soedjinah/80yo/w.24a 4. History Ro pelvis Confirmed diagnosis Monitoring
Anamnesa fraktur AP/Lat
fell 3 years ago that broke femur
her right femur. dextra
Upper leg alignment normal

Mrs. Soedjinah/80yo/w.24a 5. Geriatric 5.1 Soft diet 1700 kcal/day, low Monitoring:
Anamnesa problem immobilizati fiber, high protein Subjective
History of fall on Vital sign
Lab Support family
Alb: 3.4 g/dL 5.2 inanition Education:
Increase the
5.3 fall appetite

Mrs. Soedjinah/80yo/w.24a 6. 6.1 primary Low salt diet <2g/day Monitoring:

Hipertensi hypertention Po Amlodipin 1x5 mg Subjective
History of present ilness stage 1 Vital sign
Hypertension since 10 years SE 4 hours
ago but she didn’t take post
medicine regularly correction
Education:
control BP
Physical Examination regulary
BP = 150/90 mmHg
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mrs. Soedjinah/80yo/w.24a 7. 7.1 dt Rehydration NaCl 0,9% 1000 Monitoring:
Azotemia volume cc – continued with NaCl 0,9% Subjective
Ureum 62.8 prerenal depletion 20 tpm Vital sign
Creatinine 1.39 Urine
BUN/Cr 32.32 production
eGFR 32.9 Ur, Cr

Mrs. Soedjinah/80yo/w.24a 8. 8.1 PUD Inj omeprazole 1x40 mg Monitoring:

Dyspepsia 8.2 gastritis Nausea
Dyspepsia syndrome since syndrome erosive
she was young. She took Pedu:
antasida to relieve this eat regularly
symptom

Mrs. Soedjinah/80yo/w.24a 9. CxR Confirm diagnosis Monitoring:

Cxr: dense at suprahiler left Mediastin lateral VCSS,
pulmo, suspect mediastinum um mass dyspnea
mass CT scan Pedu:
torakal Explain about
suspicious
mass at
mediastinum
and planning
diagnose
 Risk Factor Analysis
Theory Factual

Acute diarrhea Bacteria such as salmonella, shigella, and Bacterial

E. coli, which are spread by ingesting
contaminated food or water
Viruses like rotavirus, cytomegalovirus, and
viral hepatitis
Parasites like cryptosporidium, Giardia
lamblia, and Entamoeba histolytica, which
can be contracted by ingesting
contaminated food or water
Sensitivity to certain foods such as dairy
products (lactose intolerance) and artificial
sweeteners
Intestinal disorders like Crohn's disease,
ulcerative colitis, celiac disease, and IBS
Gallbladder or stomach surgery
Hereditary disorders like cystic fibrosis and
enzyme deficiencies
Disorders of the pancreas or thyroid
Cancer-fighting radiation therapy to the
abdomen or pelvis
 Risk Factor Analysis
Theory Factual

Hipertensi stage Hypertension Older Age

1 1. Older Age
2. Race blacks.
3. Family history.
4. Being overweight or obese.
5. Not being physically active.
6. Using tobacco.
7. Too much salt (sodium) in your
diet.
8. Too little potassium in your diet.
9. Too little vitamin D in your diet
10. Drinking too much alcohol
11. Stress
12. Certain chronic conditions (high
cholesterol, diabetes, kidney disease
and sleep apnea)
 Manajemen analysis
Theory Factual
Acute inflamatory diarea The principal components NaCl 0,9% 20 tpm
of the treatment of acute Po Attapulgite 2tab/
diarrhea are fluid and diarrhea (maximal 10 tab /
electrolyte replacement, day)
dietary modifications, and
drug therapy antibiotic:
Infu ciprofloxacin 2x400mg

Hypertension stage 1 Monotherapy, until SBP < Amlodipin 1x5 mg

150 mmHg, DBP < 90
mmHg
 Problem Analysis
Shigelosis
Leukositosis
EIEC

EHEC Acute diarrhea Azotemia Prerenal

Moderate Dehydration

Shigelosis

Colorectal Ca

Geriatric Problem Mediastinum mass

Poor gygiene
Inanition Imobilization Tinea Corporis
 Condition this morning
• GCS 456
• BP 140/80mmHg
• HR 88 bpm
• RR 20 tpm
• Tax 36,4 0C
Thank you
• Factors associated with variation in diarrhoea occurrence by age
• Effect of seasons
• Diarrhoea admissions were particularly high in July (Fig. 1). Seasons were significantly associated with admissions for diarrhoea, with
the dry season having the highest likelihood (HR 1.308, p=0.000) and highest probability (Fig. 2) of diarrhoea admission at any age.
July, August, October and December significantly influenced age of admission for diarrhoea, p=0.000, p=0.005, p=0.002 and p=0.011,
respectively. The types of diarrhoea were relatively evenly distributed throughout the year except dysentery, of which 30% were
admitted in October and November. Climate and diarrhoea occurrence were moderately associated and inversely proportional:
correlation coefficient (r) 0.469, regression coefficient -13.762 for temperature and correlation (r) 0.648, regression coefficient -0.65
for rainfall. Temperature had 22% (r2 =0.22) effect on diarrhoea occurrence while rainfall had 42% (r2 =0.42).
• Effect of infections
• The commonest infection, malaria, also had the highest co-occurrence with diarrhoea (58.1%) (Table 1).
• Effect of undernutrition
• Undernutrition was significantly associated (p=0.000) with the age of occurrence of diarrhoea (Table 2). Protein-energy malnutrition
had the highest risk for diarrhoea occurrence at any age. In comparison with anaemia, under-weight was also associated with high
likelihood of diarrhoea occurrence (HR 2.064), (Fig. 2).
• Effect of district of residence
• The risk for admission for diarrhoea varied among districts, with the highest probability in Ulanga and Morogoro urban. The ordered
comparative risk at any age was: Morogoro urban (HR 1.418), Ulanga (HR 1.364), Mvomero (HR 1.183), Kilosa (HR 1.177), Morogoro
rural (HR 1.002), Kilombero (HR 0.554).
• Effect of sex
• Although the male child was more likely to get diarrhoea (HR 1.064) than the female, sex did not have a significant effect on the age
at which children were admitted for diarrhoea (Table 2).