DUTY REPORT12TH FEBRUARY 2014Resident on duty: dr. WahyuGP on duty: dr. WidyaCo-Assistant on duty:Dian, Nindya

PATIENT RECAPITULATION

FloorPatient (8)3Mrs. Syamsiar, 67 years old, 2nd day of feverMr. Slamet, 71 years old, 1st day of fever, low intake in geriatric4Mrs. Maryati, 51 years old, hyperglycemia, bronchopneumoniaMrs. Romlah, untreated AIDS , hyperglycemia, low intake, oral candidiasis5Mrs. Sukinah, 74 years old with CHF FC III ec old anterior MCI with hypoalbuminemia, 1st degree AV block and hypertension, hyperglycemia on DM type IIMrs. Jusna, dyspepsia with grade II hypertensionMrs. Supartini, 64 years old, ascites ec cirrhosis hepatic

6Mr. Suparno, 57 years old, hyperglicemia on type II DM, stage IV CKD

PATIENTS IDENTITYName:Mrs. SSex:FemaleAge:74 years oldJob:Housewife Religion:IslamMarital Status:MarriedAddress:Prumpung, East Jakarta

ANAMNESISAuto and alloanamnesis on February 12th 2014 at 9 PM in the PU ward of RSPAD Gatot Soebroto.

Chief Complaint:Patient complain of swelling on both of her feet

Additional Complaint:Difficulty of sleeping at night

CURRENT ILLNESSPatient was admitted into the PU ward at 6 PMPatient referred into RSPAD from Hermina. Patient complained of swelling on both of her feet from 1 week before admitted into the hospital. Patients feet starting to swell and gradually followed by her stomach and both of her hands.Patient denied neither chest pain nor chest discomfort. Patient often woke up at night and felt difficult to breath from 1 month ago. Patient felt more comfortable sleeping with a one pillow. PND (+), OP (-), DOE (-).Patient denied any cough, fever, sweating at night and loss of weightDefecation and urination within normal limit

CURRENT ILLNESSPatient has diabetes mellitus type II for 8 years, regularly controlled by insulin (8-8-10) and regularly check her illness to RSPAD every month. Patient felt a tingling sensation on both of her feet for a long time. Patient denied any visual and hearing loss. Patient also has an uncontrolled hypertension for 10 years

PAST ILLNESSHeart disease deniedUric acid deniedChronic cough denied

Heart disease deniedDiabetes deniedMalignancy deniedStroke denied

FAMILY ILLNESS

HABITS AND LIFESTYLESmoking (-)

PHYSICAL EXAMINATIONVITAL SIGNSGeneral State:Moderate SicknessConsciousness:Compos MentisBlood Pressure:145/60 mmHgHeart Rate:110 x/minuteRespiratory Rate:21 x/minuteTemperature:36,2oCBody Weight:50 kgBody Height:150 cmBMI:22,22 (Normoweight)

PHYSICAL EXAMINATIONGeneral ExaminationHead: NormocephalEye: anemic conjunctiva (-/-), icteric sclera (-/-)Ears: normotia, discharge (-)Nose: septum deviation (-), discharge (-)Mouth: oral trush (-), leukoplakia (-)Neck : lymph nodes enlargement (-)Thorax: symmetric, intercostal retraction (-)Cor: regular 1st and 2nd heart sound, murmur (-), gallop (-) Pulmo: vesicular breathing sounds, rales +/+ at basal wheezing -/-Abdomen: distended (+), bowel sound within normal limit, shifting dullness (+), hepar & lien not palpable, absence of painExtremities: CRT

LABORATORY RESULTS

JENIS PEMERIKSAANHASILNILAI RUJUKANHematologi rutin:Hb13,013 - 18 g/dlHt4040 52 %Erythrocyte5.14.3 - 6.0 mil /ulLeukocyte9.0004800 - 10800/ulThrombocyte333.000150000 - 400000/ulMCV7780 96 fLMCH2527 - 32 pgMCHC3332 36 g/dL

JENIS PEMERIKSAANHASILNILAI RUJUKANKimia klinik:Albumin3.0 ()3.5 5.0 mg/dlUreum68 ()20 - 50 mg/dlCreatinin1.30.5 1.5 mg/dlRandom Blood Glucose260 ()< 140 mg/dlSodium129 ()135 147 mmol/LPotassium4.13.5 5.0 mmol/LChloride9995 105 mmol/LAcetone-/Negative-/Negative

26 hours before36 hours before

ECGST elevation on lead V1, V2, V3, V4. Serial EKG persistent ST elevationHR 84 x/m, sinus rhythm, normoaxis, QRS complex, 0.12s, PR interval 0,22s 1st degree AV block

CHEST X-RAY (7th January 2014)

CTR 55% Congestion (-) Infiltrate (-)Bilateral pleural effusion

RESUMEPatient complain of swelling on both of her feet from 1 week before admitted into the hospital. Patients feet starting to swell and gradually followed by her stomach and both of her hands. PND (+) History of type II DM since 8 years ago, regularly controlled by insulin (8-8-10), history of uncontrolled hypertension since 10 years agoPE shows BP 144/60 mmHg, minimal rales at basal, ascites (+), pitting edema on both lower extremitiesLR shows hipoalbuminemia and hyperglycemiaChest X-ray shows cardiomegalyECG shows old anterior MCI with 1st degree AV block

PROBLEMS LISTFuctional CHF grade III ec old anterior MCI with hypoalbuminemiaHypertension grade I1st degree AV block Hyperglycemia on DM type II

ASSESMENT

Functional CHF grade III e.c old anterior MCI with hypoalbuminemiaAnamnesis Bilateral swelling on both of her feet from 1 week agoParoxysmal Nocturnal Dyspnea/PND (+)Physical examination Rales +/+, pitting edema on both lower extremitiesAdditional examination LR: Hypoalbuminemia, Chest X-ray: Cardiomegaly, ECG: Old anterior MCIDiagnostic plans Chest X-rayEchocardiographyTherapeutic plansFurosemid 2x 20 mg

Hypertension Grade IAnamnesisHistory of uncontrolled hypertension since 1980Physical ExaminationBlood Pressure : 145/60 mmHgTherapeutic plansCaptopril 3x6,25mg

1st Degree AV BlockECG

Prolonged PR interval 0,22s

Hyperglycemia on DM type IIAnamnesis History of controlled DM type II since 2006PF Parasthesia on both lower extremitiesLaboratory resultRBG : 260 mg/dlDiagnostic plansFBG, PPBG, HbA1CTherapeutic plansNovorapid 3 x 4 unit

PROGNOSISQua ad vitam:BonamQua ad functionam:DubiaQua ad sanationam:Dubia ad bonam

THANK YOU

CommentsDr. GatutDr. Gatut thinks the patient has a pleural effusion on 7th January 2014 and should be doing an serial chest x-ray to determine whether there is still a pleural effusion or not because the pleural condition could be much worse right now.Dr. DharmawanDr. Dharmawan thinks this patient should be given oral hyperglycemic agent first, evaluate it then adjust the therapy based on the latest laboratory results. However the therapy options can be adjusted according the current clinical conditions and the physicians choice.Insulin use indicationsNo effect from oral hyperglycemic agentNo effect from maximal dose of hyperglycemic agentOrgan disfunction (heart, liver, kidney)

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