Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 27 views

    Morning Report Case: 17th Dec 2013

    Uploaded by

    Sunardiasih
    A 73-year-old Indonesian Hindu woman presented with nausea, vomiting, and epigastric pain for 6 hours. She has a history of diabetes mellitus, hypertension, and a fall 3 months ago resulting in left leg pain. On examination, she appeared weak with normal vital signs. Laboratory tests showed hyponatremia, elevated blood glucose, and reactive leukocytosis. She was assessed with uncontrolled diabetes, dyspepsia, controlled hypertension, and electrolyte abnormalities. Her treatment plan included hospitalization, IV fluids, insulin therapy, antacids, and monitoring.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd

    Morning Report Case: 17th Dec 2013

    Uploaded by

    Sunardiasih
    27 views22 pages
    A 73-year-old Indonesian Hindu woman presented with nausea, vomiting, and epigastric pain for 6 hours. She has a history of diabetes mellitus, hypertension, and a fall 3 months ago resulting in left leg pain. On examination, she appeared weak with normal vital signs. Laboratory tests showed hyponatremia, elevated blood glucose, and reactive leukocytosis. She was assessed with uncontrolled diabetes, dyspepsia, controlled hypertension, and electrolyte abnormalities. Her treatment plan included hospitalization, IV fluids, insulin therapy, antacids, and monitoring.

    Original Description:

    Original Title

    MR Diabetes

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    A 73-year-old Indonesian Hindu woman presented with nausea, vomiting, and epigastric pain for 6 hours. She has a history of diabetes mellitus, hypertension, and a fall 3 months ago resulting in left leg pain. On examination, she appeared weak with normal vital signs. Laboratory tests showed hyponatremia, elevated blood glucose, and reactive leukocytosis. She was assessed with uncontrolled diabetes, dyspepsia, controlled hypertension, and electrolyte abnormalities. Her treatment plan included hospitalization, IV fluids, insulin therapy, antacids, and monitoring.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views22 pages

    Morning Report Case: 17th Dec 2013

    Uploaded by

    Sunardiasih
    A 73-year-old Indonesian Hindu woman presented with nausea, vomiting, and epigastric pain for 6 hours. She has a history of diabetes mellitus, hypertension, and a fall 3 months ago resulting in left leg pain. On examination, she appeared weak with normal vital signs. Laboratory tests showed hyponatremia, elevated blood glucose, and reactive leukocytosis. She was assessed with uncontrolled diabetes, dyspepsia, controlled hypertension, and electrolyte abnormalities. Her treatment plan included hospitalization, IV fluids, insulin therapy, antacids, and monitoring.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 22

    MORNING REPORT CASE

    17th Dec

    2013

    PATIENTS IDENTITY
    Name Age Gender Ethnicity Religion Occupation Address ToA 15:25:36 : SMAA : 73 yo : female : Bali : Hindu : housewife : Bukit Tunggal 24 dps : 17 December 2013 at

    ANAMNESIS
    Chief complain : Nausea Present History : Patient came with chief complaint of nauseated since 6 hours BATH. Nausea was persist all the day and getting better with rest and getting worse if patient wake up. The nausea was accompanied with vommiting +/- 5 times today and the vomit contained meal that patient eat before, without blood. This was make reduced patient ability to do activities.

    Patient also complained pricking pain at the epigastrial area since 6 hours BATH. It happen suddenly and persist all the day. It was said to be getting better with rest but the pain didnt completely removed.
    History

    of fever , cough or short breathness was denied Defecation and urination was said to be normal.

    Past illness history About 3 months ago , patient fell off from her bed , and patient complain pain at her left leg. Patient was admitted to the hospital. Since then patient complained she cant sit by herself nor walk. At that time patient also has the same symptoms as today. Patient was hospitalized and given some medicines but patient forget their name. Patient also got her blood sugar checked and said her blood sugar at time was high around 500 mg/dL and was given insulin injections for 3 days then continued with oral drugs. Patient wa said to have history of hypertension since 3 years ago. Patient routinely control to the doctor and toke captopril routinely. History of kidney, heart, and liver disease was denied

    Medication history Patient had insulin for 3 days during she was admitted previously . Patient took gluclepatic 1x1 , rheumatic medicine and captopril 2x25mg p.o. History of NSAID consumption was unknown, but she was said to take analgetic drugs to relieve pain on her left leg. It toke the medication once every 2 days during 1 months.

    Family History :
    None

    of her family member that known to have same complaint as patient. Theres no history of asma, hypertension , diabetes mellitus and heart disease.

    Social history Since 3 months ago patient activities was limited to the bed due to her leg pain. Most of the self care activities was aid by family member.

    PHYSICAL EXAMINATION
    General appearance GCS VAS Vital Sign: BP RR PR tax BW BMI : weak : E4V5M6 : 0/10

    : 120/70 mmHg : 24 x/min : 100 x/min : 37,4C : 60 kg : 23,4 kg/m2

    BH : 160 cm

    PHYSICAL EXAMINATION
    Eyes : conj. Pale (-/-); icterus (-/-); Rp +/+ isocoric, oedema palp. (-/-)

    ENT : Tonsils T1/T1; pharyngeal hyperemia (); tongue normal; lip cyanosis (-) Neck : JVP RP 0 cmH2O; lymph node enlargement (-)

    PHYSICAL EXAMINATION
    Thorax : Simetris, retraction (-) Cor Inspection : Ictus cordis unseen Palpation : Ictus cordis unpalpable Percussion : UB : ICS II LB : at MCL S ICS V RB : at PSL D Auscultation : S1 S2 single regular, murmur (-) Po

    Inspection : Symetric (static and dinamic) Palpation : VF N/ N Percussion : sonor/sonor Auscultation : vesicular +/+, Rh -/-, wh -/-

    PHYSICAL EXAMINATION
    Abdomen : Inspection Auscultation Percussion Palpation
    : distention (-), ascites (-) : bowel sounds (+) normal : tymphany : liver, spleen unpalpable, localised pain ( epigastrium )

    Extremities: Warm +/+ edema -/+/+ -/localised pain thigh (+) , crepitation (+) S

    Complete Blood Count (17/12/13)


    Parameter WBC Result 27,0
    88,8 %
    5,78 % 4,92% 0,40 % 481 %

    Unit 103/L

    Remarks H

    Reference range 4,5 11,00

    -Ne
    -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT MPV

    24,0
    1,56 1,33 011 130
    3,91 10,4 31,6 80,9 26,5 32,7 15,6 528 4,53

    103/L
    103/L 103/L 103/L 103/L 106/L g/dL % fL pg g/dL % 103/L fL

    47,00 80,00
    13,0 40,0 2,00 10,00 0,00 5,00 0,0 0 2,00

    L L L

    4,50 5,90 13,50 17,50 41,00 55,00 80,00 100,00 26,00 34,00 31,00 36,00 11,60 14,90

    H L

    150,0 440,0 6,80 10,00

    Blood Chemistry Panel (17/12/13)


    Parameter
    Albumin SGOT SGPT BUN Creatinine BG

    Result
    2,95 18,8 12,5 14 0,64 245

    Unit
    g/dl U/L U/L mg/dL mg/dL mg/dL

    Remarks
    L

    Reference range
    3,4 4,8 11,00 33,00 11,00 50,00 10,00 23,00 0,50 1,20

    80 - 100

    Blood Gas Analysis (17/12/13)


    Parameter pH pCO2 pO2 HCO3TCO2 BE(B) SO2c Natrium Kalium Result 7,54 32 71 27,4 28,4 51 96 121 3,6 Unit mmHg mmHg mmol/L mmol/L mmol/L % mmol/L mmol/L L Remarks H L L H Reference range 7,35 7,45 35,00 45,00 80,00 100,00 22,00 26,00 24,00 30,00 -2 2 95,00 100,00 136,00 145,00 3,5 5,1

    Thorax x-ray & BOF

    Thorax x-ray & BOF


    Thorax / Chest X-ray : Aortoslerosis Pleural plaque Susp Cysticercosis Spondylosis thoracalis BOF : Susp batu opaque ginjal dextra Spondylosis lumbalis Suspek cysticerosis

    ECG (17/12/13)

    ECG (17/12/2013)

    Rhythm sinus Axis N ST-T change (-) Conclusion : Sinus takikardi 110 x/minutes

    ASSESMENT

    DM type II uninvestigated dyspepsia Controlled hypertension Hyponatremia hypoosmolar evolemic chronic asymptomatic ec loss and low intake Obs leucocytosis ec susp reactive

    PLANNING

    Therapy
    Hospitalized IVFD NS 20 tpm Diet DM 2000 Kkal Aspart 3 x 8 U SC Glargin 0-0-0-10 U SC Captopril 2x25 mg (Po) Pantoprazole 1x 40 mg (iv) Antasid 3x C I (Po) Sucralfat 3x C 1(Po) Paracetamol 3x 500 mg (Po) enoxaparin 1x 0,4cc (Sc)

    Pdx
    POC EGD igG

    7 days

    anti H pylori BSN, 2 hours pp, HbA1C Lipid profile CT scan pelvis Blood smear

    Monitoring
    Vital

    sign, symptoms

    THANK YOU

    You might also like