MORNING REPORT

Friday, February 1st, 2019

Physician in charge
I : dr. Novita, dr. Kasman, dr. Fiqih, dr. Ramadi
II CVCU : dr. Ema
II HCU : dr. Astri
II UGD : dr. Ernes, dr. Roni
Chief on duty : dr. Yuni
Consultant on duty : dr. Herwindo SpPD
Fasilitator : dr. Herwindo SpPD
 Summary of Database
Mrs. T/56 yo/ward 28 bed 17
Autoanamnesa and Heteroanamnesa with her daughter
Chief Complaint:
stiffness over her arms and legs
History of Present Illness:
- Patient suffered from stiffness over her arms and legs since 5 days before she got
hospitalized. Stiffness increasingly burdensome until the patient cannot hold or stand.
- Patients with a history of MRS at Lawang Hospital for 2 days 5 days ago. After being
treated for 2 days the patient was declared cured and sent home. The day after she is
home, patient got the hospitalization again 1 day later with the same complaint.
- The patient now claims that rigid complaints have diminished.
 Summary of Database
Past Medical History:
Never been sick like this before

Family History:
-

Social History:
she is a pensiouner

Review of System:
fever (-), malaise (+)
 Physical Examination
General appearance look moderately ill Sat O2 98% room air
GCS 456 CM VAS 0/10
BP 120/70 mmHg PR 90 bpm regular strong RR 18 tpm Tax 36,7oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Chvostek sign (+) ER--> (-) ward
Neck JVP R+ 2cmH20

Chest Symmetrical, retraction (-)

Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-

Sonor | Sonor Vesicular | Vesicular -
|- +|+
Sonor | Sonor Vesicular | Vesicular -
|- +|+
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, shifting dullness (-)

Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany

Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralisation (-), trosseau sign (+)
5|5
 Laboratory Findings (31/01/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 15.380 4.700 – 11.300 /µL Ureum 20,50 20-40 mg/dL

Hemoglobine 11,0 11,4 - 15,1 g/dl Creatinine 0,93 <1,2 mg/dL

PCV 30,20 38 - 42% Natrium 134 136-145 mmol/L

Thrombocyte 295.000 142.000 – 424.000 /µL Kalium 2,99 3,5-5,0 mmol/L

MCV 82,10 80-93 fl Chlorida 101 98-106 mmol/L

MCH 29,9 27-31 pg Calcium 7,9 7,6-11,0

Eo/Bas/Neu/ 0.0/0.3/85.5/9 0-4/0-1/51-67/ Phosphor 4,7 2,7 – 4,5

Limf/Mon .6/4.6 25-33/2-5
RBS 109 < 200 mg/dl

SGOT 22 0-40 U/L

SGPT 20 0-41 U/L

Albumin 4,52 3.5-5.5 g/dL

Electrocardiography (31/1/19)
 Electrocardiography (31/01/2019)
• Sinus rhythm, HR 83 bpm
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0,20 s
• QRS complex : normal
• ST segment : no ST elevation
• QT interval : 0,37 s
• QT corrected : 0,45 s
• T wave : normal

Conclusion : Sinus rhythm, 100 bpm, QT corrected 455

msec (prolonged)
Chest X-Ray (19/09/2018)
 Chest X-Ray (19/09/2018)
• AP position, asymmetric, enough KV, less inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 60%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: looks cardiomegaly

Clinical Picture

Trousseae’s sign
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. T/56 yo/ward 28 bed 17 1. Muscle spasm 1.1 Parathyroid - Bolus Calcium gluconate 1 PMo
+ trousseau sign Hypoparathyroi hormon gram iv (done in ER) Subjective
Subjective + History of dism Vitamin D serum - Continue drip calcium ca serum
- stiffness over her arms and hypocalcemia Calcium urine gluconate 1 gram iv in 500 every 6 hours
legs 1.2 Vitamin D cc D5% in 8 hours target:
deficiency 7mg/dL
Objective Peroral
- Trousseae sign + 1.3 - Vitamin D 0.25 to 0.5 mcg
Hyperphosphat daily PEd
ECG 31/1/19 emia - 1000 mg elemental lifelong
Sinus rhythm, QT corrected 455 calcium daily (total diet + calcium and
msec (prolonged) supplement) vitamin D
- KSR 3 x 600mg supplementa
Laboratory tion,
Calcium 7,9 mg/dL exposure to
sunrise
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. T/56 yo/ward 28 2. Hypokalemia 2.1. Urine - Confirm the diagnosis PMo
+ muscle spasm Gittelman electrolyte - Extra potassium diet Subjective,
Subjective syndrome SE post
- stiffness over her arms correction
and legs 2.2 Barter
syndrome PEdu
Laboratory Extra
Potassium 2,99 potassium
diet,
Cause
hypokalemia
Effect of
hypokalemia
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. T/56 yo/ward 28 3. SOB + 3.1. CXR - Nebul ventolin 3 PMo
wheezing Bronchospasm Spirometry times per day Subjective,
Subjective dt. No 1 Wheezing
- Shortness of breath
3.2. Asma PEdu
Objective bronchial Cause of
Wh +|+ mediobasal bilateral shortness of
breath, plan
to nebulizer 3
times a day
 Problem Analysis

Hyperphosphatemia Hypoparathyroidism Vitamin D

Deficiency

Hypocalcemia

Gittelman syndrome
Hypokalemia
Barter syndrome

Asma bronchial SOB + Wheezing Bronchospasm

 Risk Factors Analysis
Problem Theory Patient
Hypocalcemia • low levels of vitamin D, which makes it unknown
harder to absorb calcium
• medications, such phenytoin,
phenobarbital, rifampin, corticosteroids,
and drugs used to treat elevated calcium
levels
• Pancreatitis
• Hypermagnesemia and hypomagnesemia
• Hyperphosphatemia
• Septic shock
• Massive blood transfusion
• Renal failure
• Certain chemotherapy drugs
• “Hungry bone syndrome,” which may
occur after surgery for
hyperparathyroidism
• Removal of parathyroid gland tissue as
part of surgery to remove the thyroid
gland
Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis
Problem Theory Patient
Hypocalcemia • Symptoms (carpopedal spasm, tetany, Symptomatic patients
seizures) (carpopedal spasm)
• A prolonged QT interval
• In asymptomatic patients with an acute
decrease in serum corrected calcium to
≤7.5 mg/dL (1.9 mmol/L) - Bolus Calcium gluconate 1
• We recommend IV calcium for gram iv (done in ER)
symptomatic patients (carpopedal spasm, - Continue drip calcium
tetany, seizures) and for patients with a
prolonged QT interval. We also suggest IV gluconate 1 gram iv in
calcium for asymptomatic patients with D5% in 60 minutes
an acute decrease in serum corrected
calcium to ≤7.5 mg/dL (1.9 mmol/L)

• Oral calcium supplementation: 2-4 g of

elemental calcium/day
• IV calcium (1 or 2 g of calcium gluconate,
equivalent to 90 or 180 mg elemental
calcium, in 50 mL of 5 percent dextrose or
normal saline) can be infused over 10 to
20 minutes
• Vit D supplementation
Management Analysis

Hypocalcemia management
 Key Message Management

Patients with hypocalcemia who are severely symptomatic (carpopedal spasm, tetany,
seizures, decreased cardiac function, or prolonged QT interval) require rapid
correction of calcium levels with intravenous (IV) calcium therapy. We also suggest IV
calcium therapy in asymptomatic patients with an acute decrease in serum corrected
calcium to ≤7.5 mg/dL (1.9 mmol/L).
Most patients with hypoparathyroidism require lifelong calcium and vitamin D
supplementation
 Key Message Social

Hypocalcemia may be the result of low calcium production or insufficient calcium

circulation in your body. A deficiency of magnesium or vitamin D is linked to most
cases of hypocalcemia.
Many hypocalcemia cases are easily treated with a dietary change. Taking calcium,
vitamin D, or magnesium supplements, or eating foods with these can help treat it.
Spending time in the sun will increase your vitamin D levels. The amount of sun
needed is different for everyone. Be sure to use sunscreen for protection if you’re in
the sun for a long time. Your doctor may recommend a calcium-rich diet plan to help
treat it as well.
 Condition This Morning

• GCS : 456
• BP : 130/80 mmHg
• HR : 92 bpm, regular, strong
• RR : 20 tpm
• Tax : 36.6
• SaO2 : 98% Room air