SUNDAY SHIFT

March, 1th 2020

PATIENT’s DATA

Team 1 Team 2
• 10 • 12
patient patient

Team 3 Team 4
• 17 • 14
patient patient
PATIENT’s DATA

New Patients

• 10patients

Transferred Patients

• 0 patients

Dead Patients

• 1 patients
 New Patients on Saturday Shift
No Name / Age
1 Mrs. Mataniah/80yo
2 Mr. Ahyar/57yo
3 Mrs. Rukayah/ 58 yo
4. Mr. Husaini/57 yo
5. Mrs. Norhidayah/ 31 yo
Diagnosis
1. General weakness
2. OA Genu
3. Anemia Normocytic Normochromic
1. Post Vitrectomy
2. DM type II
3. Hipertensi stage II on treatment
1. Febrile Day 7
2. HF Stage C FC II
3. Hipertensi Stage II
1. Ulcus Pedis Sinistra
2. Anemia NN+ Melena
3. HF stage C FC II
1. Anemia relate to CKD
2. CKD st V on HD
3. HT Urgency
No Name / Age
6 Mr. Fahrul Raji/22yo
7 Ms. Dewi Aprianisa/21 yo
Diagnosis
1. AML M3 on treatment
2. Nausea+ vomit+ epigastric pain
3. Febrile Day 2+ leukositosis
1. Bisitopenia+ leukositosis with
myeloblast+ history of gum bleeding
2. Anemia NM
3. Trombositopenia relate to malignancy

New Patients on Sunday Morning Shift

No Name / Age Diagnosis
8 Mrs. Siti Lamina/ 56yo 1. DM type II non obese with HF and
Hypertensi complication
2. HF mr EF AHA Stage III NYHA FC II
9 MRS. Normasdah/49yo 1. AML M6 with Anemia and severe
trombositopenia
10 Mr. Wagiyo/60 yo 1. Colic renal susp. Nefrolithiasis dd PNC
2. Acute on CKD ec PNC
3. UTI Complicated
4. BPH
 MORNING REPORT
Monday, march 01 2020
MR Facilitator :dr. Djallalluddin, M.Kes, Sp.PD-KKV, FINASIM
Dr. dr. Muh. Darwin Prenggono,Sp.PD-KHOM, FINASIM
dr. Nanang Miftah Fajari, Sp.PD -KEMD
Supervisor on duty : dr. Fauzia Sp.PD
Chief on duty : dr. Fathony
IIA : dr. Indra
IB : dr. Ikbal
IA : dr. Jumria
 POMR 1. 1. Febris days 7 + macula
granumalutosa with itch and squama
generalista + history of used steroid

Case contents POMR 2 Cushing Syndrome

POMR 3 UTI complicated

Summary of database

Physical examination POMR 4 HF

Lab POMR 5 Type II Diabetes Melitus

ECG POMR 6 hypertension stage I

Chest x ray
POMR 7 epigastric pain + nausea+ vomit

Clinical apperance
POMR 8 Decrease of vision
 SUMMARY OF DATABASE
Identity : Mrs. R/ 58 yo
Chief complaint : fever
Autoanamnesis

Present Medical History

Patient came to Emergency Room of Ulin Hospital suffered about fever since 1 week
ago. Fever happened continuously. Fever happened especially in the evening and the
temperature was not too high. It could improve with antipyretic drugs but in a few hour the
fever was rises again. Cough (-), History of gum bleeding (-)

She also complained about about itching all of body since 7 days ago. Itching was felt
initially on the face then spreads to the body and leg. She felt reddish and scaly skin
initially on the face then spreads to the body and leg, She talked that happened when she
ate shrimp. Previously itchy after eating shrimp before the itching happened, but only
slightly. She talked that felt uncontinous and it could improved with cetirizine.
 SUMMARY OF DATABASE cont.

Patient also felt Nausea, without vomiting since 1 week, and she felt epigastric pain

especially when missed meal time , then she vomit since 3 days ago 2-3 times/day.

contain fluid. There’s no food residue or blood. She had decrease of appetite since 7

days ago. She ate 2-3 spoon every meal time. But didn’t have decreased of body weight.

She didn’t had this complaint before. Because of this, she felt weak.

She also felt shortness of breath since 1 month ago, shortness of breath worsened by activity and

usually better with rest. She should sleep with 2-3 pillows on her back to improve shortness of

breath. the patient has woken up in the middle of the night due to shortness of breath but during

2 days the patient said shortness of breath has been reduced. Chest pain (-), dizziness (-).

Patients complain of pain when urinating, but this complaint is felt not every time,

She routine went to Cardiology Poly since 2 month and was given 2 drugs but she didnot

remember name of the drugs. She was diagnosed hypertrofi of heart.

 SUMMARY OF DATABASE cont.

She also complained about Her vision was also decreased since 1

years ago, and want to operate but could not because her blood

glucose so high (500).

she had Diabetes Mellitus problem since 2 years ago. she checked

his blood glucose level was 500. she was consumed metformin and

Glibenclamid but did not routinely control. She also had

Hypertension since 2 years ago and didn’t control too.

 SUMMARY OF DATABASE cont.

Past Medical History

(-)
Family Medical History
Hypertension (-), DM (-), symptoms like her (-)

Medication History:
She consumed steroid drug (Lanadexon) before every day since 1 years ago, but in 1
month she consumed routinely 3 times/ day with divoltar,she bought the drugs. But 1
weeks patient did not consumed steroid. Patient took lanadexon because it made appetite
increase and the body felt good

Allergic History:
There was allergic history of food especially shrimp.

Social History
She have 3 children. She was a housewife. Alcohol (-), cigarretes (-) ,Multi sexual partners
(-) tattoo (-)
Physical Examination
General appearance: looked Height: 152 cm
moderately ill Weight: 52 kg
GCS : E4V5M6 BMI: 22 kg/m2
(normoweight)
BP: 150/90 mmHg PR: 81 bpm, RR: 20 tpm Tax: 36.6 oC SpO2 : 98 % on room air
regular
pale conjunctiva (-), icteric sclera (-), moon face (+), eritema (+), squama (+),
Head
OD> 2/60, OS > 2/60
JVP R+2 cm H2O, 30o position, enlargement of lymph nodes colli (-), buffalo hump
Neck
(+), squama (+)
Ictus visible and palpable at ICS V 2cm lateral midclavicula line sinistra
LHM: ictus
Heart RHM: SL D
S1S2 single, gallop (-) systolic murmur (-)
Symmetric (+), retraction (-)
Chest
Palpation Percussion Vesicular Rhonchi Wheezing
Lung n n s s v v - - - -
n n s s v v - - - -
n n s s v v - - - -
Physical Examination
Inspection: flat, hyperpigmentasi , eritema (+), squama (+)
Auscultation: normal bowel sound
Percussion: tympanic, liver span 10 cm, traube’s space tympanic, shifting
Abdomen dullness (-)
Palpation: epigastric pain (+) ,liver and spleen not palpable

Extremities Warm acral, CRT < 2” , edema (-/-), bruishing (-), Atropy skin (+)
 Laboratory Finding
29/2/2020
Lab Result Value Lab Result Value
Complete Blood Count Diff count
Haemoglobin 12.0 12.0 – 16.0 Basophil 0.0-1.0
Leukocyte 13.5 4.0 – 10.5 Eosinophil 1.0-2.6
Erythrocyte 4.81 4.00 – 5.30 Neutrophil 60.4 50.0-81.0
Haematocrit 38.2 37.0 – 47.0 Lymphocyte 22.8 20-40
Platelet 600 150 – 450 Monocyte 2.0 – 8.0
MCV 79.4 75.0 – 96.0
MCH 24.7 28.0 – 32.0
RDW-CV 14.9 12.1 – 14.0
CKMB 16
RBF 113 >200
 Laboratory Finding
29/2/2020
Lab Result Value Lab Result Value
Kidney Electrolytes
Ureum 6 0-50 Natrium 138 136-145 Meq/L
Creatinine 0.66 0.72 – 1.25 Kalium 3.6 3.5-5.1 Meq/L
Uric Acid Klorida 105 98-107
Calcium
Na Corrected
Ca Corrected
Serum Osmolality
 Laboratory Finding
29/2/2020
Lab Result Value Lab Result Value
Liver and Biliary Faal Hemostasis
Total Protein PT 9.9-13.5 detik
Globulin Control PT
Albumin 3.2-4.6 g/dL INR
SGOT 93 5-34 U/L APTT 22.2-37.0 detik
SGPT 55 0-55 U/L Control APTT
Bilirubin Total 0.20-1.20 g/dL
Bilirubin Direk 0.00-0.20 g/dL
Bilirubin Indirek 0.20-0.80 g/dL LDH
AFP
Gamma GT
Alkali Phosphatase
 Laboratory Finding
29/2/2020
Lab Result Value Lab Result Value
Urinalysis Sediment
Macroscopic Leukocytes 3-7 0–3
Color yellow Yellow Erythrocytes 0-2 0–2
Cloudy Clear Clear Epithelia +2 +1
SG 1.010 1.010 – 1.015 Crystal - -
pH 6.0 4.5 – 8.0 Cylindrical - -
Ketone trace - Bacteria - -
Protein-albumin - -
Glucose - -
Bilirubin - -
Occult blood - -
Nitrit - -
Leukocytes +2 -
ECG 29/02/2020
ECG Interpretations

February 29th 2020

Heart Rate : 100 bpm
Frontal Axis : LAD
Horizontal Axis : Clock wise rotation
PR interval : 0.16 seconds
QRS complex : 0.08 seconds
QT interval: 0.40 seconds

Conclusion : Sinus Rhythm HR 100 bpm, LAD

CHEST X-RAY

AP position, enough inspiration, low

KV
Soft tissue and bone are normal
Trachea in the middle
Right hemidiaphragma was
domeshape, left hemidiaphragm was
domeshape
Costo phrenico angel d/s were sharp
Pulmo : infiltrate at lower lobe right
lung and parahiler dextra
Cor: site normal, CTR > 50%, boot
shape

Conclusion : cardiomegaly
Clinical Appearance
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 1. Febris days 1.1 dermatitis Prick test - Ns 0.9% 1500/24 jam • Vital sign
History of fever 7 days 7 + macula atopi - Inj dipenhidramin 3x10
Itching since 7 days granumalutos 1.2 related to mg
reddish and scaly skin. a with itch steroid with 2nd - Consul to dermato - Education:
Steroid used and squama indection venerology • Explain about
History of allergic generalista + 1.3 psoriasis with her disease
history of 2nd infection and
used steroid complication
T : 36.6 C and the
Reddish and squama all of area planning to
the patient
• Keep higine of
skin
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 2. Cushing 2.1 ACTH Dexamethasone - Confirm diagnosed • Vital sign

History of consumed steroid Syndrome independent supresion test - Tapp off steroid - ACTH plasma
Felt weak. 1.1.1 iatrogenik dt - BMD
exogenous Free cortisol
History of HT 1.1.2 endogenous - Abdominal
History of DM USG
1.2 ACTH dependent ACTH serum - Education:
Moon face (+) 1.2.1 Adenoma • Explain
Red cheeks (+) hipofisis about her
Buffalo humpt (+) 1.2.2 neoplasma non disease and
Muscle arthropy (+) hipofisis (ACTH complication
ectopic) and the
planning to
the patient
PAPDI hal 2064
Alur diagnostik
 Initial Planning Planning Planning
CUE AND CLUE Problem List Monitoring and
Diagnose Diagnose Therapy Education

Mrs. R / 58 yo 3. UTI complicated 3.1 Lower UTI Urine - Inj ceftriakson 2x1 gr VS
Pain when urinating 3.1.1 cultur - Po Pracetamol 3x500
History Febris 7 days Sistitis sensitivity mg Subjective CBC,
3.1.2 test Urinalysis / 3 days
Urethritis

3.2 Upper UTI P Edu :

VAS 2-3 1.2.1 Clean the hygiene,
T 36.6 pyelonephriti
s
Leukocyt 13.500

urinalisa
Lekocyt 2+

Sedimen urin
Keukocyt 3-7
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 4. HF 4.1 HHD echocardiography - Bed rest - Sign of

History Shotness of breath 4.2 diabetic - Low salt diet 2 overload
Control to cardio poly routinely cardiomiopaty gram/ day - ASCVD score
Take drugs for hipertrofi of heart - Candesartan 1x8  target LDL
mg 70
- Atorvastatin 40mg 0-
0-1
TD 140/90 JVP 5+2 cm H2O - CPG 1x75mg po - Education
N 81 aboaut her
T 36.6 disease and
Rr 20x how to control
Spo2 98%
it
ECG : Sinus
tachycardia HR
100 bpm

Chest Xrays :
Cardiomegaly
(boot shape)
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 5. . Type II - Education and support - Subjective

Suffered DM since 2 years with RBG Diabetes Melitus - Consul to ophtalmoloy - Fasting Blood
500 specialist Glucose and 2
History consumed metformin and hour Blood
glibenklamid - Medical Nutrition Glucose
Decrease vision since 1 year Therapy - HbA1C
- DM diet : - Lipid Profile
Basal calorie : 25x52 = - ECG
1300 kcal/day - Renal function
Total calorie : 1300 + 15% - Albumin
= 1495 kcal/day
Carbohydrate 50 % = 747 Planning
RBG 113 kcal/day = 186 gram/day Education
Protein 0.8 Educate how to
gram/kgBW/day = 41.6 control his blood
gram /day = 166 kcal/day sugar and prevent
Fat = 299 kcal/day = 33.2 the complication
gram/day

- Physical Activity 
Flexibility training and
balance training 2
times/week @ 30
minutes
CUE AND CLUE

Problem Initial Planning Planning Planning

Monitoring
List Diagnose Diagnose Therapy and Education

Ny. R / 58 yo 6. - Low salt diet < 2 gram/day Subjective

History of hypertension since 2 Hypertension - Candesartan 8 mg 0-0-1 Target BP <
years stage I 140/90mmHg
TD 150/90 - Lipid Profile
- ECG
ECG : Sinus - Chest Xray
tachycardia HR 100 - Urinalysis
bpm - Renal
function
Chest Xrays : Planning
Cardiomegaly Education
(boot shape) Educate how to
control his
blood pressure
and prevent the
complication
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 7. Nausea + 7.1 gastropati NSAID - Endoscopy - Inj metoklopra,id Vital sign
Nausea and vomit vomit + and glucocorticoid 3x10 mg
Consumed lanadexon and divoltar epigastric 7.2 gastropati - Inj omeprazole Any stomach
pain diabetic 1x40 mg discomfort,
7.2 PUD nausea, vomit

Edu
Epigastric pain (+) Educate the
patient about
the disease,
prognosis and
treatment,
Educate to
consume safe
medication
and diet
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose Monitoring and
Diagnose Therapy Education

Mrs. R / 58 yo 8. Decrease 8.1 retinopati Funduscopy - Consult Vital sign

Decrease of vision of vision diabetic ophthalmology
8.2 katarak senilis Any stomach
History of DM
discomfort,
nausea, vomit

Edu
OD > 2/60 Educate the
OS > 2/60 patient about
the disease,
prognosis and
treatment,
Educate to
consume safe
medication
and diet
 Problem Analysis
Dermatitis with
secondary infection Moon face

Cushing Syndrome
Cushing Syndrome
Itching and reddish hypertension

Steroid used
HF
Epigastric
pain+nausea+vomit

NSAID used Diabetic Decrease of visus

RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL
Cushing • Tumors on the pituitary gland This patient used
Syndrome • Adrenal tumor glucocorticoid more than 1
years
• Exogenous glucocorticoids
• Hypercortisolemia
• Ectopic ACTH
RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL
UTI Common cause of UTI
• Female anatomy
• Sexual activity
• Certain types of birth control. Female anatomy
Menopause
• Urinary tract abnormalities
• Blockages in the urinary tract
• A suppressed immune system.
• Catheter use
• A recent urinary procedure.

MayoClinic
 Management Analysis
Problem Theory Factual

Principal: control ACTH

Surgery
Cushing Syndrome Confirm the diagnosed
Radiation
Medication
Manajemen analysis
 • Patient must give enough information
about her disease

Key • The disease is a progressive, the

treatment and complication must be
Messag understood by the patient and family
• We give education to control her
e Social disease with take his medicines
regularly and visit the doctor.
• Keep hygiene
 • S : itching
• GCS : E4V5M6
CONDITI • BP : 120/80 mmHg

ON THIS • HR
• RR
: 88 bpm, regular, strong
: 22 tpm
MORNIN • Tax : 36.6 C
G • SpO2 : 99 % on room air
• RBG : 141
THANK YOU