MORNING REPORT

Date : September 2, 2019

Physician in charge
I : dr. Dimas, dr. Husni, dr. Ferdi, dr. Zainal, dr. Rezdy
II CVCU : dr. Ponda, dr. Amanda
II HCU : dr. Arde
II UGD : dr. Astri, dr. Efriko
Chief on duty : dr. Rima
Consultant on duty : dr. Dewi Indiastari, SpPD
Facilitator : dr. Budi D. Machsoos, SpPD-KHOM
 Summary of Database
Mrs E./47 yo/ward 26 bed 6
Heteroanamnese
Chief Complaint:
Decrease of Consciousness
History of Present Illness:

• Patient came with a history of gradual loss of consciousness since 2 days ago, accompanied by relapsing right-

sided headaches. There were nausea and vomiting. Patient looked limp since 1 week ago accompanied by

relapsing fever, which is improved with administration of paracetamol.

• Patient also complains of coughing since 8 days ago and the phlegm is difficult to be thrown out. Patient has

shortness of breath since 8 days ago, improved when sitting. There was history of fluid obtained in the right

lung and has been taken 8 months ago. The patient has been treated for 4 days in the previous hospital and

she was found anemia with Hb: 7.6. Then she got 4 bags of PRC and the Hb improved to 10,4.

• History of routine menstruation every month, 8-9 days per cycle. The patient do not use contraception.

• History of weight loss for about 22 kilograms in the last 8 months. History of HT and DM are denied.
 Summary of Database
Past Medical History:
Hospitalized in Baptis Hospital, got transfused 4 packs of PRC

Family History:
No history of malignancy in her family

Social History:
She is a housewife with two sons

Review of System:
Fever (-), nausea vomiting (-)
 Physical Examination
General appearance lookmoderately ill Sat O2 99 % on NC 3 lpm
GCS 245 VAS 2/10
BP 150/90 mmHg PR 82 bpm regular strong RR 22 tpm Tax 36,7 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor 3 mm/3 mm
Neck JVP R+ 0 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor - | Vesicular +|+ -|-
Sonor | Sonor -|- +|+ - |-
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 (+) 9tpm, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space dullness
Extremities Edema (-), pale (-), MMT 5 | 5

Neurological Status Physiological reflex BPR +2/+2, KPR +/+2, Achilles +2/+2
Pathologic Reflex chaddock (-/-), oppenheim (-/-), babinski (-/-); Lateralization(+) sinistra
 Laboratory Findings (31/8/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 5.210 4.700 – 11.300 /µL Ureum 21 20-40 mg/dL

Hemoglobine 7,6 11,4 - 15,1 g/dl Creatinine 0,42 <1,2 mg/dL

PCV 32,5% 38 - 42%

Thrombocyte 409.000 142.000 – 424.000 /µL Natrium 132 136-145 mmol/L

MCV 73,9 80-93 fl Kalium 4,5 3,5-5,0 mmol/L

MCH 23,6 27-31 pg Chlorida - 98-106 mmol/L

Eo/Bas/Neu/ 0,0/0,2/77,1/8 0-4/0-1/51-67/ RBS 114 < 200 mg/dl

Limf/Mon ,3/14,4 25-33/2-5
PPT - 9.3-11.4 seconds
SGOT 30 0-40 U/L APTT - 24.8-34.4

SGPT 16 0-41 U/L INR - 0.8-1.30

Albumin 2,73 3.5-5.5 g/dL Ca 125 79,36 < 35

 Blood Gas Analysis (31/8/2019)

With Room Air NC 2 lpm Normal

pH 7,36 7.35-7.45
pCO2 30 35 – 45 mmHg
pO2 80,7 80 – 100 mmHg
HCO3 20 21 – 28 m mol/L
O2 saturation 98% > 95 %
BE -4,6 (-3) - (+3) m mol/L
Temperature 37,2 C
Hb 11,1
Conclusion: metabolic acidosis fully compensated
 Urinalysis (29/8/2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity cloudy 10 x
Color yellow Epithelia 42 ≤1

pH 7,0 4.5 – 8.0 Cylinder Negative

SG 1,015 1.005 – 1.030 Hyaline Negative

Glucose +2 negative Granular Negative

Protein negative negative Other negative

Keton Negative negative

Bilirubin Negative negative 40 x

Urobilinogen Negative negative Erythrocyte +2 ≤3
Nitrite Negative negative Leukocyte ≤5
Leukocyte 4 negative Crystal Negative
Erythrocyte >100 Bacteria Negative ≤23 x 103/ml
Other
Electrocardiography (31/8/2019)
 Electrocardiography (31/8/2019)

• Sinus rhythm, HR 84 bpm

• Frontal Axis : normal
• Horizontal Axis : CCWR
• P wave : 0,06 s
• PR interval : 0,16 s
• QRS complex : 0,08 s
• ST segment : no ST elevation
• QT interval : 0,28 s
• T wave : normal

Conclusion : sinus rhythm 84 bpm CCWR

Chest X-Ray (30/8/2019)
 Chest X-Ray (30/8/2019)

• AP position, symmetric, enough KV, enough inspiration

• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S were down shape
• Phrenico-costalis angle D and S were dull
• Pulmo: bronchovesicular pattern increased
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: bilateral pleural effusion, pneumonia

Abdominal USG (30/8/2019)
 Abdominal USG (30/8/2019)

 Hepar : a bit enlargement; echoparenchym was rough; VH/VP was normal;

tiny multiple nodule at the right and left lobe (+)
 Gall bladder : size and shape were normal; no visible stone/mass/sludge; wall
thickening (-)

 Pancreas : size was normal; homogenous parenchym; calcification (-)

 Lien : size was normal; mass (-); cyst (-)
 Renal D/S : size was normal; echo cortex normal; margin of sinus cortex was
definite; ectasis at pelvicocalyceal (-); no visible stone/mass/cyst

 Vesica urinaria : enough content; smooth wall, mass (-), calcification (-)
 Prostat : size was normal, mass (-), calcification (-)
 ascites and pleural effusion
Conclusion: Chronic liver disease dd metastase, Ovarian cyst dextra dd endometriosis,
ascites and pleural effusion
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 1. DOC + left 1.1 brain Head CT- - Bed rest PMo:
extremity metastatic process scan + - O2 NC 2-4 lpm CT scan result
lateralization 1.2 CVA Infarct contrast - fluid diet 6x200 cc
Subjective 1.3 Septic - IVFD NS 1500 cc/24 hrs PEdu:
- gradual loss of consciousness 2 encephalopathy - plan to consult to neurology disease
days ago + accompanied by department (wait for CT Scan
relapsing right-side headaches result)

Objective
GCS 245
Lateralization -/+ (sinistra)
Physiological Reflex:
BPR +2/+2
KPR +2/+2
Achilles +2/+2

Abdominal USG (30/8/2019)

- chronic liver disease dd
metastase
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 2. Pleural 2.1 Meig - Abdomnal CT- Non farmacology PMo:
effusion + syndrome Scan with contrast - Bed rest pleural and
Ovarian cyst + - ascites and pleural - O2 NC 2-4 lpm ascites fluid
Subjective
Ascites + increase fluid sitology - Ascites and pleural fluid sitology
- fluid obtained in the right lung 8
Ca 125 analysis punction analysis
months ago
- Consult to OBG departement PEdu:
Objective
to plan laparotomy for management
RR: 22 tpm
diagnostic and staging of medication
SpO2: 99% NC 3 lpm
Confirm diagnosis
- Percussion dullness bilateral
lung area
- Rhonkhi +/+ basal
- vesicular sound <</<< basal

Ca-125: 79,36

CXR (30/9/2019)
- pleural effusion dextra sinistra

Abdominal USG (30/8/2019)

- chronic liver disease dd
metastase
- ovarian cyst dextra dd
endometriosis
- ascites and bilateral pleural
effusion
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 3. Septic - sputum Non farmacology PMo:
condition dt CAP culture + AB - Bed rest cough, fever, SOB,
sensitivity - O2 NC 2-4 lpm RR
Subjective
test
- Patient looked limp since 1
Pharmacology Education and
week ago accompanied by
- IV Levofloxacin 1x750 mg management of
relapsing fever, which is
- IV Ceftriaxone 2x1 g medication
improved with administration of
paracetamol
- Patient also complains of
coughing since 8 days ago and
the phlegm is difficult to be
thrown out.

Objective
GCS 345
RR 22 tpm
Rhonchi +/+ medial

Laboratory
Neutrofil: 77,1

CXR (30/9/2019)
- pneumonia

BGA (31/8/2019)
- Metabolic Acidosis Fully
compensated
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 4. HT stage 1 4.1 Primary funduscopy Non farmacology BP
4.2 Secondary - Bed rest
Subjective - equal fluid balance
History of HT was denied
Pharmacology
Objective - PO Amlodipin 1x10 mg
BP: 150/90 mmHg
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 5. Anemia 5.1 Chronic - SI,TIBC Non farmacology PMo:
hypochromic disease - blood smear - Bed rest CBC per 3
Subjective microcytic 5.2 Fe Deficiency - fluid diet 6x200 cc days
- 4 days in the previous hospital (improved)
with Hb: 7.6, got 4 bags of PRC Pharmacology PEdu:
and the Hb improved to 10,4 confirm diagnosis disease

Objective
H/N: Anemic (+)

Laboratory
Hb: 10,4
MCV/MCH: 73,9/23,6
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs E./47 yo/ward 26 bed 6 6. Moderate 6.1 Hypercatabolic Non farmacology Albumin
Hypoalbuminemia state - Bed rest
Subjective 6.2 Low intake - fluid diet 6x200 cc, extra Education
- pleural fluid history protein and
- low intake management
Pharmacology of medication
Objective -
- look moderately ill
- dullness lung bilateral
percussion

Laboratory
Albumin: 2,73 (1/9/2019)

CXR (30/9/2019)
- pleural effusion dextra sinistra

Abdominal USG (30/8/2019)

- ascites and bilateral pleural
effusion
 Problem analysis
Pleural
Ascites Ovarian cyst
effusion

Meig Syndrome

Chronic disease Immunocompr Hypercatabolic Brain

Fe deficiency omised state state metastase

CAP Hypoalbumine
Anemia HM mia DOC
Septic
condition
Ascites >>

Septic
DOC RAAS activation HT
encephalopathy
Meig’s Syndrome
• Meig’s syndrome is defined as a condition that meets
the following diagnostic criteria : the presence of
pleural effusion and ascites, the existence of benign
and solid ovarian tumors with the gross appearance of
fibroma.
• The ascites and pleural effusion rapidly resolve after
removal of the tumor
• It is more common in postmenopausal woman with an
average age of 50 yo
Meig’s Syndrome
• The pathogenesis of the production of ascites and pleural effusion in
Meig’s syndrome is unknown. Many reports suggest that the ascitis fluid
result from edematous fibromas that leak fluid or increased lymphagial
pressure in the pelvis and abdomen caused by the tumor itself
• It has also been supposed that the pleural effusion arises secondary to
the ascites through a congenital defect of the diafragma or the
diafragmatic lymphatic system. Besides, a theory about subastances
such as VEGF that raises caplillary permeability and some inflammatory
cytokines including IL 1, IL 6, IL 8 are possible etiologies of ascites and
hydrothorax formation
 Condition This Morning

• GCS : 345
• BP : 130/100 mmHg
• PR : 90 bpm
• RR : 20 tpm
• Tax : 36,9
• SpO2 : 99% NC 4 lpm
Thank you