morning report

1. MORNING REPORT
Palma ward
4th
July, 2023

2. Patient Identity
• Name : Mr. RM
• Age : 37 years old
• Sex : Male
• Education : Senior High School

3. A 37 year-old male was admitted to R.D. Kandou
Hospital at Palma ward on
4th
of July, 2023
Chief complaint: Loss of consciousness

4. Present Medical History
• The patient is a referral from Sentra Medika Hospital with a loss of consciousness. The
patient has been treated at Sentra Medika Hospital for 3 days and referred at the
request of the family, because according to the family there was no change during
treatment.
• According to the family, the patient initially had complaints of coughing up mucus
since 2 weeks ago. Cough containing clear mucus without blood.
• Complaints are also accompanied by shortness of breath which has been felt
suddenly since 2 weeks ago worsen over the last 1 week.
• The patient also had a fluctuating fever that had been felt since the last 1 week. The
patient has nausea but does not vomit.
• The patient's family said that the patient had experienced a decrease in
consciousness since 1 day ago.
• The family denied that the patient had previously experienced chest pain, dizziness,
night sweats, weight loss, decreased appetite, one-sided weakness.
• Defecation and urination no complaints. The patient's urine volume was 1,200 cc per
24 hours ago.

5. Past Medical History
• History of type 2 DM since 2021 but never had DM
treatment
• Denied history of hypertension, hyperuricemia,
heart, lung, or kidney disease

6. Family History
• None experienced the same illness

7. Physical Examination
• GC: Severely ill. Sens : Delirium
• BP 86/50mmHg, PR 156x/m regular, RR 30x/m, T 36.8o
C,
SpO2: 98% via NC 5 lpm
• Head : conj. anemic (-), scl. icteric(-), nuchal rigidity (+),
light reflex ↓ / ↓
• Neck : JVP 5+2 cmH20
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC not palpable
– Perc : left border: ICS V anterior axillary line
right border: ICS IV right sternal line
– Ausc : SI-II regular, murmur (-), gallop (-)

8. Physical Examination
• Lung :
Insp : Symmetric R = L
Palp : Stem fremitus R = L
Perc : Sonor
Ausc : Vesicular breath sound, ronkhi +/+, wheezing +/+,
slam -/-
• Abdomen
Insp : Flat
Ausc : Normal bowel sound
Palp : Supple, epigastric pain hard to evaluate, Liver and spleen
no enlargement
Perc : Tympanic
• Extr : warm, edema -/-, CRT <2”

9. CHEST RADIOGRAPH

10. RONTGEN INTERPRETATION
Rontgen components Interpretation
Identity, Name, Diagnosis Same
Side Marker (right/left) Correct
Film Type
(AP/PA/Lateral/Erect)
Anteroposterior (AP)
Film Quality:
• Adequate Inspiration?
• Thoracal vertebrae?
• Clavicula and Sternum
symetric in middle
Adequate (10th Posterior Costae can be seen)
Adequate
Symetric
Tube/Cable No
Cor + CTR 47,5%
Pulmo (Trachea position,
bronchi, hilar, vascular
pattern, infiltrate, cavity,
fibrosis, nodul, Pleural
thickening
Opacity spots on both lungs, especially on the upper and
middle fields

11. RONTGEN INTERPRETATION
Rontgen components Interpretation
Soft tissue and Bone
• Neck, supraclavicula,
axilla, chest, mammae,
upper abdomen, gastric
gas, shoulder joint,
scapula, clavicula,
vertebrae, costae, and
sternum
Normal
Diaphragma Normal
Mediastinum (Shape,
diapraghm height, free air,
tenting, elevation,
Flattening)
Normal
Sinus Costovertebrae Sharp
Sinus Cardiophrenicus Sharp
CONCLUSION : Suspected pulmonary TB

12. ECG

13. ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Rhytm Sinus Rhythm
Speed / HR (times/mnt) 82 bpm 300/R-R’
Axis Normal Normal
Morphology P wave Normal Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,12” 0,12” – 0,20”
QRS complex duration 0,08” 0,05” – 0,11”``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION : Sinus rhytm, HR 82x/m, normoaxis

14. Lab Result 30/6/23
• Leukocyte 3.800
• Hb 12.6
• Hct 37
• Trombo 412.000
• UA 2.8
• RBG 310
• Ur 30
• Cr 0.4
• OT 17
• PT 26
• HbA1C 11.6%

15. Urinalysis 03/7/23
• Keton +3/ PH 5.5
• Protein +1

16. Urinalysis 03/7/23
• Na 127
• K 4.4
• Cl 115

17. RBG stick result 03/7/2023 –
04/7/2023
• 23.00 264 Novorapoid 6 unit IV + Levemir 10 unit SC
• 24.00 197
• 01.00 198
• 02.00 204
• 03.00 198
• 04.00 145
• 05.00 147
• 06.00 135
• 11.00 361
• 15.00 288 N10 SC

18. BGA Result 3/7/23
• pH 6,951
• PCO2 19.5
• PO2 64
• BEecf -28
• HCO3 -4.3
• TCO2<5mmol
• SO2 77%
• lac 1.90
• Impression of venous AGD
collection

19. Lab Result 3/7/23
• Leukocytes 26,900
• Erythrocytes 5.48
• Hemoglobin 15.4
• Hematocrit 46.5
• Platelets 598,000
• MCHC 33.0
• MCV 84.9
• MCH 28.0
• RBG 330
• SGOT 18
• SGPT 18
• Ur 63
• Cr 0.6
• Na 127
• K 4.2
• Cl 95
• Viral marker NR

20. BGA Result 4/7/23
• pH 7.233
• PCO2 25.0
• PO2 234
• BEecf -17
• HCO3 10.5
• TCO2 11 mmol
• SO2 100%
• lac 1.05
• Pao2 : fio2 234/1 = 234
(moderate ARDS)

21. Problem List
• Septic Shock ec Pneumonia dd Urosepsis
• Moderate ARDS
• Pulmonary tuberculosis suspected
• Uncontrolled type 2 DM
• Compensated metabolic acidosis
• Euvolemic hyponatremia(127)

22. Neurology advice
• Educate the family
• Adequate oxygenation
• Advice : Repeat BGA
• Currently no neurological deficits are found,
the patient can be consulted again if new
neurological deficits are found

23. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
1. Septic Shock ec
Pneumonia dd
Urosepsis
Post loading Nacl 0.9% 1000 cc followed by
maintenance Nacl 0.9% 500 cc / 6 hours
Levofloxacin 1x750 mg IV
Norepinephrine 1.2 ml/hour using a syringe
pump up titrated until MAP > 65
Examine IVC => patient is restless
Consult PPRA for vancomycine
Insert NGT and urinary catheter
Consult ICU
Check BGA
Educate the family about patient’s
worsening condition
Check urinalysis
Leu 4000-10000
RR < 20
HR 60-100
Diagnostic
Care Plan

27. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
2. Moderate ARDS Adequate oxygenation
Nebuliser salbutamol 1 respule every 8
hours
RR <24x/m

31. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
3. Suspected pulmonary
TB
Check Gene Expert Diagnostic
Care Plan

36. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
4. Uncontrolled type 2
DM
Levemir 1x10 SC units
Novorapid 6 units if RBG>200
Novorapid 10 units if RBG>300
Check BG/6 hours
RBG 140-180
FBG <100

37. ADA Criteria for DMT2-2021

38. Konversi HbA1c

40. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
5. Compensated
metabolic acidosis
Monitoring vital sign/4 hr
Consult ICU
Check BGA
Follow up treatment

42. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
6. Euvolemic
hyponatremia(127)
Post loading Nacl 0.9% 1000 cc followed by
maintenance Nacl 0.9% 500 cc / 6 hours
Na 135-153

43. Natrium Correction
– Na deficit: (135-127)x0.6x50 = 240 meq
– Na daily: 2-3 meq/kgBB = 100-150 meq
– Total Na = 340-390 meq
– Max Na / day = 8x0.6x50 = 240 meq/24hours
– NaCl 0,9% = 240/154 *1000 = 1558 ml/day
– Duration = 390/240 x 24 hours = 39 hours
– Osmolality = 2 x 127 + (330/18) + (63/6) = 282 mOsm/kg

44. Hiponatremia

45. Conclusion
• Has been reported a case of 37-year-old male who
was admitted to R. D. Kandou Hospital at Palma ward
with chief complaint Loss of consciousness. After a
thorough history-taking, physical examination, and
laboratory-radiology workup, patient was diagnosed
with Septic Shock ec Pneumonia dd Urosepsis,
Moderate ARDS, suspected pulmonary tuberculosis,
Uncontrolled type 2 DM, Compensated metabolic
acidosis, Euvolemic hyponatremia(127)

46. Prognosis
• Ad vitam : Dubia ad malam
• Ad functionam : Dubia ad malam
• Ad sanasionam : Dubia ad malam

47. THANK YOU