MORNING REPORT

Sunday, February 24th, 2019.

Morning Shift
Physician in charge
I : dr. Wahyu, dr. Firdha, dr. Rezdy, dr. Fiqih
II Medical Consultation : dr. Kristia
II Intensive : dr. Dipto
II HCU : dr. Fikri
II ER : dr. Iin, dr. Adys
Chief on duty : dr. Nadina
Consultant on duty : dr. Syifa Mustika, SpPD-KGEH
Facilitator : dr. Budi Dharmawan M., SpPD-KHOM
 Summary of Database
Mrs. SH/48 yo/ward 28
Autoanamnesa with Patient
Chief Complaint:
Stiff hands
History of Present Illness:
The Patient came to ER with 2 weeks history of hands stiffness. The Complaint emerged
slowly, exacerbating since yesterday. Stiffness in the hands cause her right and left thumbs to
fold, pain was present when it is moved.
Muscle cramps throughout the body, especially at the end of extremities, following with
numbness in end part of extremities.
Decreased of appetite over 2 weeks.
History of having same symptoms in January, 2018.
History of having thyroidectomy in 2015. Routinely control in Endocrinology Polyclinic
of RSSA/month, and routinely consuming Euthyrox 1x100 mcg but poorly controlled
consuming Callos 4x500 mg.
 Summary of Database
Past Medical History:
History of thyroidectomy surgery in 2015 due to mass.
Routinely control in Endocrinology Polyclinic of RSSA/month, and routinely consuming Euthyrox
1x100 mcg but poorly controlled consuming Callos 4x500 mg. She had taken Cavit-D3 for 1 week,
but it was not continued due to uncovered by insurance.

Family History:
There’s no family confirmed having same illness with her

Social History:
She is a housewife, having a son. In the last 2 weeks She mostly spend her activities on bed since
she felt unwell. She has a health insurance.

Review of System:
Stiff hands, generalized body cramps, history of thyroidectomy surgery in year 2015.
 Physical Examination
General appearance looked moderate ill BMI 22 Sat O2 99 on room air
GCS 456 VAS 1/10 on passive movement
BP 120/80 mmHg PR 78 bpm regular strong RR 18 tpm Tax 37 oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Meningeal Sign (-), Pupil Isocor, Chvostek Sign (-)
Neck JVP R+0 cmH20, There’s no surgical scar
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, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-), Trousseau’s sign (+)
5|5
Genitourinary UOP = 1,5 litre/day Urine color clear yellow
 Laboratory Findings (24/02/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 5.230 4.700 – 11.300 /µL Ureum 9 20-40 mg/dL

Hemoglobine 12,2 11,4 - 15,1 g/dl Creatinine 0,72 <1,2 mg/dL

PCV 37,3 38 - 42% Osm - 275-295 mOsm/kg

Thrombocyte 290.000 142.000 – 424.000 /µL Natrium 142 136-145 mmol/L

MCV 86,9 80-93 fl Kalium 3,23 3,5-5,0 mmol/L

MCH 28,4 27-31 pg Chlorida 107 98-106 mmol/L

Eo/Bas/Neu/ 38/1,1/46,4/3 0-4/0-1/51-67/ RBS - < 200 mg/dl

Limf/Mon 8,6/10,1 25-33/2-5
PPT - 9.3-11.4 detik
SGOT 22 0-40 U/L APTT - 24.8-34.4

SGPT 12 0-41 U/L INR - 0.8-1.30

Albumin 4,16 3.5-5.5 g/dL Calcium 5,4 7,6-11,0 mg/dL

Bilirubin total - <1.0 mg/dl Phosphate 5,6 2,7-4,5 mg/dL

Bilirubin direct - <0.25 mg/dl EGFR - ml/min/1.73 m2

Bilirubin indirect - <0.75 mg/dl BUN/Cr -

 Urinalysis (24/02/2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity Clear 10 x
Color Yellow Epithelia 0,4 ≤1

pH 6,5 4.5 – 8.0 Cylinder Negative

SG ≤1,005 1.005 – 1.030 Hyaline -

Glucose Trace negative Granular -

Protein Negative negative Other -

Keton Negative negative

Bilirubin Negative negative 40 x

Urobilinogen 3,2 negative Erythrocyte 0,8 ≤3
Nitrite negative negative Leukocyte 0,3 ≤5
Leukocyte negative negative Crystal -
Erythrocyte negative negative Bacteria 5,5 ≤23 x 103/ml
Other -
 Blood Gas Analysis (24/02/2019)

With Room Air Normal

pH 7,31 7.35-7.45
pCO2 39,3 35 – 45 mmHg
pO2 37,4 80 – 100 mmHg
HCO3 20,1 21 – 28 m mol/L
BE -6,3 (-3) - (+3) m mol/L
O2 saturation 71,3 > 95 %
Hb 11,4
Temperature 37
Conclusion: possibly mixed with vein blood sample
Chest X-Ray (24/02/2019)
 Chest X-Ray (24/02/2019)

• AP position, asymmetric, enough KV, enough 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 50%, shape Normal, elongation aorta (-),
cardiac waist (+)

Conclusion: normal chest x-ray

Electrocardiography (23/02/2019)
 Electrocardiography (23/02/2019)
• Sinus rhythm, HR 78 bpm regular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0,16”
• QRS complex : 0,09”
• Q wave : normal
• QT interval : 0,48”
• ST segment : Normal, isoelectric
• Others : Normal

Conclusion : Sinus rhythm, HR 78 bpm, Prolonged QT

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SH/48 yo/ward 28 1. Acute 1.1 PTH Non Pharmacology Pmo:
Symptomatic Parathyroid - Regular diet 1700 S, VS, ECG,
Subjective hypocalcemia hormone cal/day Calcium
Stiff hands, generalized body deficiency serum level
cramps, history of Pharmacology 2 hour post
thyroidectomy surgery in - Drip 10 ml Calcium correction,
year 2015. gluconate 10% solution Vitamin D
in 100 ml NS 0,9% 100 serum
Objective cc over 20 minutes level,
GCS 456 Magnesium
BP 120/80 Serum
PR 78 bpm Level
RR 18 tpm
SatO2 99% Ped:
Chvostek sign (-) Diagnosis,
Trousseau’s sign (+) planning
diagnosis,
Laboratory planning
Calcium 5,4 mg/dL therapy
Phosphate 5,6 mg/dL

ECG
Sinus rhythm HR 78 bpm,
prolonged QT interval
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SH/48 yo/ward 28 2. 2.1 PTH Non Pharmacology Pmo:
Hyperphospha Parathyroid - Regular diet 1700 S, VS,
Subjective temia + hormone cal/day Calcium
Stiff hands, generalized body hypocalcemia deficiency serum
cramps, history of + muscle 2.1.1 Pharmacology level,
thyroidectomy surgery in cramps + Complication - PO Calcium Carbonate Vitamin D
year 2015. prolonged QT thyroidectomy 3x500 mg serum level
interval surgery - PO Calcitriol 2x0,5 mcg
Objective
GCS 456 Ped:
BP 120/80 Diagnosis,
PR 78 bpm planning
RR 18 tpm diagnosis,
SatO2 99% planning
Chvostek sign (-) therapy
Trousseau’s sign (+)

Laboratory
Calcium 5,4 mg/dL
Phosphate 5,6 mg/dL

ECG
Sinus rhythm HR 78 bpm,
prolonged QT interval
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SH/48 yo/ward 28 3. History of (-) (-) Non Pharmacology Pmo:
thyroidectomy - Regular diet 1700 S, VS,
Subjective surgery cal/day Calcium
History of thyroidectomy serum
surgery in year 2015. Pharmacology level,
- Levothyroxine Vitamin D
Objective 1.6 mcg/kg body serum
GCS 456 weight  1x100 mcg level, PTH
BP 120/80 - PO Calcium Carbonate level, fT4,
PR 78 bpm 3x500 mg TSH
RR 18 tpm - PO Calcitriol 2x0,5 mcg
SatO2 99% Ped:
Diagnosis,
Laboratory planning
Calcium 5,4 mg/dL diagnosis,
Phosphate 5,6 mg/dL planning
therapy
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SH/48 yo/ward 28 4. Mild 4.1 Low Intake (-) Non Pharmacology Pmo:
Hypokalemia 4.2 Hypo - Regular diet 1700 S, VS, SE,
Subjective magnesemia cal/day ECG,
Decreased of appetite - Extra Potassium diet Magnesemi
a
Objective Pharmacology
GCS 456 (-)
BP 120/80 Ped:
PR 78 bpm Diagnosis,
RR 18 tpm planning
SatO2 99% diagnosis,
planning
Laboratory therapy,
SE 142/3,23/107 mmol/L extra
potassium
ECG diet
Sinus rhythm HR 78 bpm,
prolonged QT
 Problem Analysis

History of
Thyroidectomy Parathyroid
Hyperphosphatemia
Surgery Hormone Deficiency
Complication

Stiff Hands,
Trousseau’s Sign,
Hypocalcemia
generalized body
cramps
 Risk Factors Analysis
Problem Theory Patient

Acute Signs and Symptoms of hypocalcemia Signs and Symptoms of

Symptomatic • Peri-oral and peripheral paresthesia hypocalcemia
hypocalcemia • Tetany, muscle cramps, Chvostek’s sign (tapping over facial nerve • Muscle cramps
causes facial muscles to twitch) • Trousseau’s Sign
• Cardiac disturbances  bradycardia, arrhythmias, hypotension, • Cardiac disturbances 
prolonged QT interval prolonged QT interval
• CNS disturbances  irritability, confusion, intellectual • CNS disturbances 
deterioration, seizures irritability, confusion,
Causes of hypocalcemia intellectual deterioration,
• Hypoparathyroidism (congenital, autoimmune, after thyroid or seizures
parathyroid surgery) Causes of hypocalcemia
• Vitamin D deficiency (decreased intake, malabsorption or failure of • Hypoparathyroidism (after
synthesis or activation), inadequate dietary calcium thyroid or parathyroid
• Renal disease surgery)
• Hypomagnesaemia (consider PPI associated hypomagnesaemia)
• Drugs (e.g. phenytoin, bisphosphonates, rifampicin,
chemotherapy), blood transfusion, contrast dye)
• Hyperphosphatasemia
• Respiratory alkalosis (increased albumin binding, relative fall in
free ionized calcium)
• Acute pancreatitis (free fatty acids chelate calcium)
• Malignancy: osteoblastic metastases (e.g. breast cancer, prostate
cancer), tumor lysis syndrome (following chemotherapy)

GHNHSFT Drug & Therapeutics Committee October 2015. Acute Treatment of Hypocalcaemia (adults)
 Risk Factors Analysis
Problem Theory Patient

Hyperphosphatemi Definitions of Hypoparathyroidism: Signs and Symptoms of

a + hypocalcemia + Duration: hypocalcemia
muscle cramps + • Temporary (transient): Defined as up to 12 months in duration • Muscle cramps
prolonged QT following cervical surgery • Trousseau’s Sign
interval suspect dt • Permanent: Lasting longer than 12 months following cervical • Cardiac disturbances 
Parathyroid surgery prolonged QT interval
hormone Characteristic: • CNS disturbances 
deficiency dt Clinical irritability, confusion,
thyroidectomy • Subjective hyperesthesias of the distal extremities intellectual deterioration,
surgery • Perioral numbness/tingling seizures
complication • Nocturnal leg cramps Causes of hypocalcemia
• Chvostek/Trousseau signs • Hypoparathyroidism (after
Biochemical thyroid or parathyroid
• Hypocalcemia surgery)
• Total calcium, corrected to a serum albumin of 4.0
ng/mL, <8.5 mg/dL.
• Ionized calcium <1.15 mmol/L
• Hypoparathormonemia
• Can vary from lab to lab based on assay used (i.e., <12
pg/mL), refer to specific test published ranges.

AACE/ACE. Postoperative Hypoparathyroidism, Endocr Pract. 2015;21(No. 6) 675

 Risk Factors Analysis
Problem Theory Patient

Hyperphosphatemi Calcium Prophylaxis Regimens: She routinely consuming

a + hypocalcemia + Calcium: Euthyrox 1x100 mcg but poorly
muscle cramps + • Calcium Carbonate: 1000-3000 mg/day controlled consuming Callos
prolonged QT • Calcium Citrate: 1000-3000 mg/day 4x500 mg. She had taken Cavit-
interval suspect dt Vitamin D: D3 for 1 week, but it was not
Parathyroid Preparation continued due to uncovered by
hormone • 1,25 di-OH-cholecalciferol: 0,5-2 mcg/day insurance.
deficiency dt • 25 di-OH-cholecalciferol: 1000 IU/day
thyroidectomy • 25 di-OH-cholecalciferol: 50000 IU/week x 8-12 weeks
surgery
complication 1. Calcium ± Vitamin D could be given; many calcium citrate
preparations contain vitamin D
2. Calcium salt selection can be a matter of availability, cost,
surgeon preference, and patient tolerance
3. A decision to prescribe vitamin D might be based off of a
preoperative 25-OH vitamin D level if available
4. Patients given prophylaxis should be monitored for rebound
hypercalcemia and/or vitamin D toxicity as appropriate
5. Universal calcium prophylaxis is used by some practitioners
for parathyroid and total/completion thyroid surgery to
facilitate same-day discharge (28)

AACE/ACE. Postoperative Hypoparathyroidism, Endocr Pract. 2015;21(No. 6) 675

 Key Message Pathophysiology

Hanne (A.J.) Van Ballegooijen. 2014. The role of vitamin D and parathyroid hormone in cardiovascular health. DOI: 10.13140/RG.2.2.22269.36321
Key Message Diagnosis

AACE/ACE. Postoperative Hypoparathyroidism, Endocr Pract. 2015;21(No. 6) 675

 Management Analysis
Problem Theory Patient

History of CLINICAL HYPOTHYROIDISM The patient routinely consumes

thyroidectomy If there is no residual thyroid function, the daily replacement Euthyrax (Levothyroxin) 1x100
surgery dose of levothyroxine is usually 1.6 μg/kg body weight (typically mcg
100–150 μg), ideally taken at least 30 min before breakfast.

Harrison’s Principles of Internal Medicine 20th Edition

 Key Message Management

GHNHSFT Drug & Therapeutics Committee October 2015. Acute Treatment of Hypocalcaemia (adults)
Key Message Management

AACE/ACE. Postoperative Hypoparathyroidism, Endocr Pract. 2015;21(No. 6) 675

 Condition This Morning

• GCS 456, Compos Mentis

• BP: 120/70 mmHg
• PR: 80 bpm
• RR: 18 tpm
• T.ax: 37OC
• VAS: 0/10
 Prognosis

• Ad vitam : dubia
• Ad functionam : dubia
• Ad sanationam : dubia
Deeb, K. K., Trump, D. L. and Johnson, C. S. (2007) ‘Vitamin D signalling pathways in cancer: Potential for anticancer therapeutics’, Nature Reviews Cancer. doi:
10.1038/nrc2196.