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Belajar membuat MR: DOC + SEPTIC ENSEFALOPATHY + GERIATRIC brrr
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Transcript of Belajar membuat MR: DOC + SEPTIC ENSEFALOPATHY + GERIATRIC brrr
MORNING REPORTThursday, November 5th, 2015
COASS IN CHARGE:Ricky Randana
Dadik Ardhi Wijaya
SUPERVISOR : dr. Gatoet Ismanoe, Sp.PD
SUMMARY OF DATABASEMr. S / 76 yo / W.26History Taking: HeteroanamnesisChief Complain: Decrease of ConsciousnessHistory of Present Illness :
Patient came with the chief complain decrease of consciousness since 1 month ago, it was gradually onset. He started difficult to communicate to his family then his son said he could not wake him up and he only lying on bed for 1 month worsening since 4 days before admission. Patient also complained cough since one month ago with sputum but hard to excrete, but there was no fever.
Previously, he got accident about 6 months ago when he repaired his house, then he fell, he got closed fracture and operation. After 3 month, he got repair for the fracture. He complained decreased of appetite since 3 months ago he took only small amount of food. (3-4 times, 5 spoon each time) and decreased of body weight about 10 kg in last 6 months. He also had wound in his back, hip, and also his right ear about 3 months ago. He cannot move his right leg for 3 months.
History of past illness : He was hospitalization 2 times. First about 6 months ago due to an accident and he was got an operation and the second times about 3 months ago because of repair post fracture operation . Family History : none of his family had a chronic disease Social History : Married with 4 child, and 5 grandchild. Pensionary. His daily activity was normal before he got an accident (6 months ago).
Physical Examination
BP: 140/70 mmHg PR : 100 regular strong RR: 28 tpm Temp.(ax): 36.80C
General Appearance : Looked severely ill GCS : 345Looked underweight
Head Anemic conjunctiva (+) Icteric sclerae (-) Wound at right auricular with necrosis tissue
Neck JPP R+0cm H20
Chest Heart ictus visible and palpable at ICS V, MCL SLHM – ictus RHM – SL D S1S2 single, murmur (-)
Lung Symmetric; SF D=S; S| S V | V Rh - - Wh - - S| S V | V - - - - S| S BV | V + - - -
Abdomen Flat, bowel sound normal, liver span 8 cm, Traube’s space tympani
Ext. Warm acral . Turgor ↓, dry skin (+)Wound at right hip, his back with excoriation and necrosis tissue, hiperemis, kalor (+)
Photo
Photo
LABORATORY FINDINGSLab Value Lab Value
Leucocyte 12140 4000-11.000/µL Na 140 136-145mmol/l
Diff count 0.0/0.0/88.3/8.4/3.3
0-4/0-1/51-67/25-33/2-5 %
K 4.34 3,5-5,0 mmol/l
Haemoglobin 8.20 11-16,5 g/dL Cl 113 98-106 mmol/l
MCV 89.40 80-93 fl
MCH 31.00 27-31pg Ureum 139.70 16,6-48,5 mg/dL
PCV 20.2% 40-47 % Creatinin 3.17 < 1,2 mg/dL
Thrombocyte 86000 142-424 1 x103/µL BUN/Cr 20.59
SGOT/AST 31 11-41U/L
SGPT/ALT 11 11-41U/L RBS 135 < 200 mg/dL
Albumin 2.30 3,5-5
PPT / INR 12.00/11.2
APTT 22.80/27.50
URINALYSIS Lab Value Lab Value
Cloudy Cloudy Clear 10 x
Color Yellow Yellow Epitel 23.3 ≤ 1lpf
pH 5.5 4,5 - 8,0 Cilinder Negative Lpf
BJ 1030 1,010 – 1,015 Hialin Negative ≤ 2
Glucose Negative Negative Granular Negative Negative
Protein +1 Negative 40 x
Keton Negative Negative Erythrocyte 2,7 hpf ≤ 3 hpf
Bilirubin Negative Negative Dysmorfic Negative Hpf
Urobilinogen Negative Negative Eumorfic Negative Hpf
Nitrit Negative Negative Leucocyte 283.8 ≤ 5 hpf
Leucocyte +3 Negative Fungi - Hpf
Blood +2 Negative Bacteria 1582.3 ≤ 23 x 103/mL
ECG
ECG
Sinus tachycardia with HR 100 bpmFrontal axis : NormalHorizontal axis : normal PR interval : 0,20 secondQRS kompleks : 0,08 secondQT interval : 0,32 secondConclusion : Sinus tachycardia with HR 100 bpm
CXR
AP position, asymmetric, KV enough, enough inspiration Soft tissue skin, bone : normal Trachea in the middle Hemidiaphragm D /S dome shape Phrenico cotalis angle Dextra & sinistra are sharp Pulmo D/S : infiltrate Cor site: N, Size: CTR 46 %Conclusion : Susp. Pneumonia
Chest X-Ray
CUE AND CLUE PL Idx PDx PTx Pmo
Male/ 76 YO/ Ward 26DOCProlonged bedriddenCough Multiple ulcus decubitusLow intake Geriatric problem
Phy. ExamGCS: 345BP: 140/70mmHgPR: 100 bpm RR: 28 tpmT.ax: 36.8 C
LabHb 8.20Leuco 12.140Ur/Cr: 139.70/3.17
UL Leucocyte : 283.5
Cxr: Susp. Pneumonia
1. DOC 1.1 Septic encephalopathy
1.2 Uremic encephalopathy
02 8 - 10 lpm via NRBM
Inj. ceftriaxone 2x1 g
Inf. Levofloxacin 1 x500mg 1x250 mg Intravena
Rehydration 2000cc in 2 hours maintenance 20 tpm
VSSubjectiveUrine output
Male/ 76 YO / W.26DOC, low intake , multiple ulcus decubitus due to prolonged bedridden
Phy. ExamBP: 140/70mmHgRR: 28 tpmPR: 100 bpmT.ax: 36.8
-Rhonki in basal dextra lung (+)-Multiple ulcus in hip dextra, auricular dextra with necrotic tissue (+)
LABLeuko : 12140Trombo 86000UL: Leuco 238.5
CXR : Susp. Pneumonia
2. Septic condition
2.1 Ulcus decubitus gr II due to prolonged bed ridden
2.2 Pneumonia 2.2.1 CAP2.2.2 Orhtostatic
2.3 UTI
Culture sputum , pus, and antibiotic sensitivity test
Bedrest with proper position and antidecubitus bed
Equal fluid balance
Inj ceftriaxone 2x1 gram
Inf. Levofloxcacin 1 x500mg 1x250 mg Intravena
Wound toilet
VS SubjSeptic shock sign
Male/ 76 YO / w26DOC, prolonged bedridden, wound at auricular and right hip, ulcus decubitus
Phy. Exam:Anemic conjunctiva (+)
LABHb: 8.20MCV: 89.00MCH: 31.00
3. Anemia NN
3.1 Chronic disease
3.2 Occult blood loss
Treat underlying disease
Subj, vital sign, Recheck cbc
Male/76 yo/W26Ax:DOCProlonged bedridden, Low intake
Phy. ExamGCS 345BP 140/70 mmHgPR 100 bpmRR 28 tpm
Lab:WBC: 12140PLT: 86.000Ureum: 139.7Creatinin: 3.17
4. Azotemia 4.1 pre renal4.1.1 Septic condition 4.1.2 Volume depletion
4.2 Renal
•Equal fluid balance
•Liquid diet 6x200cc (1cc ~ 2 calories)
•Loading fluid at ER NS 2L in 2 hours continued NS - 20tpm
VSSubjectiveRecheck ureum creatininUrine production
Male/76 yo/ W26DOCProlonged bedridden due to post fractureLow intakeMultiple ulcus decubitusContracture due to immobilitation chronic
PE :BP 140/70mmHgPR 100 bpmRhonki in basal dextra Ulcus decubitus with necrotic tissue
LABAlbumin : 2.30 g/dLLeucocyte 12140 mg/dLGDS 135
CXR: Pneumonia
5. Geriatric problem
5.1 Prolonged bed ridden
5.2 Immobilization
5.3 Constipation
5.4 Malnutrition
Proper positioning every 2 hours with antidecubitus bed
Medical rehabilitation
Inserted NGT diet: need 2100 kcal/day 6 x 200cc + extract protein
IVFD NS 1000cc / day
SubjVSUrine output