dr.

Mazen

MORNING REPORT
Wednesay, March 31st 2021

PHYSICIAN IN CHARGE :
IA : dr. Ogit, dr. Syafiq, dr. Alid
IB : dr. Nanda, dr. Vidi, dr. Puput
II Med-Con : dr. Dandi
II Incovit: dr. Mazen
II HCU : dr. Firman
II UGD : dr. Mira, dr. Caesar
II IGD Incovit: dr. Gunawan
Chief : dr. Dinda
Consultant : Dr. dr. Supriono, SpPD-KGEH

INTERNAL MEDICINE DEPARTMENT

MEDICAL FACULTY BRAWIJAYA UNIVERSITY | Dr. SAIFUL ANWAR GENERAL HOSPITAL
 Summary of Database
Mrs. IJ/ 67 yo/ P3 Incovit
Chief Complaint:
Nausea and vomitting
History of Present Illness:
Patient suffered from nausea and vomiting since 2 days ago, with the frekuency 2-3 times a
day with the contain with residual food and water.
She also complaint diarhea since 2 days ago, 4-5 times a day, blood (-) slime (-). Fever (+)
since 4 days ago, cough (-)
She also complain shortness of breath since yesterday it has been complaint with activity anosmia
(-) myalgia (-)
History of DM since more than 10 years ago. She routinely consumed glibenclamide and
metformin. History of HT or HF was denied. History of contact with Covid-19 patient (+) her sibling
was confirmed case of Covid-19.
 Summary of Database
Past Medical History:
No remarkable past medical history

Family History:
Contact with her siblings who confirmed case of covid 19

Social History:
Patient work as physician

Review of System:
Obese
Urination normal
Defecation diarrhea
 PHYSICAL EXAMINATION
General appearance looked moderatly ill GCS 456 Sat. O2 98% on NC 4 lpm
BMI 27,3 (Overweight)

BP 120/70 mmHg PR 97 bpm regular strong RR 23 tpm regular Tax 36,7 oC

Head did not performed
Neck did not performed

Chest Lung did not performed

did not performed

did not performed

Cardio did not performed

Abdomen did not performed

Extremities did not performed

UOP Hard to evaluated
 Laboratory Findings (31/3/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 4.230 4.700 – 11.300 /µL PTT 10,3

Hemoglobine 12,9 11,4 - 15,1 g/dl APTT 26,5

PCV 36,7% 38 - 42% INR 0,99

Thrombocyte 158.000 142.000 – 424.000 /µL Fibrinogen 367,4

MCV 89,3 80-93 fl D-dimer 0,69

MCH 31,4 27-31 pg Eclia NR

Eo/Bas/Neu/ 0/0/67,1/23,9 0-4/0-1/51-67/ CRP 3,75
Limf/Mon /9 25-33/2-5
Procalcitonin 0,21
NLR 2,8 OT/PT 39/24
TLC 1010 Bil T/D/I 0,31/0,14/0,17
HbA1C 16,9% Ur/Cr 74,8/1,64
RBS 308 BUN/Cr 21,3
Na 128 Cl 99
K 5.06
Chest X-Ray (31/3/2021)
 Chest X-Ray (31/3/2021)
• Cor : shape, size, and position normal
• Aorta : elongation (-), dilatation (-), calsification (-)
• Trachea : in the middle
• Pulmo : infiltrate on middle and lower lobus lung S, dominant in
perifer
• Hemidiaphragma D/S : dome shape

Conclusion:
• Pneumonia sugestif ec Viral
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Acute 1.1 GI - FL Non Pharmacology PMo
Mrs. IJ/ 67 yo/ Bougenvile
Subjective
watery Manifestation of - Swab feces • Bed rest S, VS, Fluid
Patient also complaint
diarrhea Covid-19 PCR COVID • Low Fiber Diet balance,
with Mild -19 (not UOP
diarrhea since 2days ago, 4-
to 1.2 Rotavirus available in Pharmacology
5 times a day no abdominal
pain and volume 50-100cc
Moderate RSSA) • IVFD NS 1400cc/2
Mucus (-) blood (-) Dehydratio hours and evaluating
n sign dehydration
Objective • Attapulgite 2 tab /
diarrhea max 10tab
HR 97
RR 23 • PO Zinc 3x20mg
UOP 0,3cc/kgbb/hou
Decreased Skin turgor

Daldiyono score: 3
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Nausea 2.1 GI Swab PCR Pharmacology Pmo :
Mrs. IJ/ 67 yo/ Bougenvile
Subjective
and Vomiting Manifestation of naso and • IV Ondansentron 3x8 S, VS, Fluid
Covid-19 oropharynx mg balance,
nausea and vomiting since 2
days ago, vomit contain with • IV Lansoprazole 1x30 UOP
2.2 PUD mg
food

Objective 2.3 Diabetic

gastroparese
HR 97
RR 23
Uop 0,3cc/kgbb/hour
Decreased Skin turgor

Daldiyono score :3
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Pneumonia - Swab PCR Non Pharmacology Pmo :
Mrs. IJ/ 67 yo/ Bougenvile
Subjective Covid-19 naso and • O2 NC 2-4lpm S, VS, SaO2
Patient suffered from fever since 4 Probable Case, oropharynx
days ago Moderate Pharmacology
Contact with Covid-19 patient (+)
cough (-)
degree • IVFD NS
Diarrhea (+) nausea (+),shortness of 1500cc/24hours
breath (+) • IV Azithromycin 1 x
500 mg
Objective
GCS 456 • IV Vit C 3 x 200 mg
HR 97 • PO Vit D 3 x 1000 IU
RR 23 • PO Vit B Complex 3 x 1
SaO2 93 % RA  98% on NC 4 lpm tab
CXR • PO Zinc 3 x 20 mg
Pneumonia sugestif ec Viral • Anti-viral waiting for
Swab result
Laboratory
Nlr 2.8, tlc 1.010
• Heparin 2x5000
D-dimer 0.69
Crp 3.75
Procal 0.21
Ur /Cr 74.8/1.64
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. DM type 2 - Non Pharmacology Pmo :
Mrs. IJ/ 67 yo/ Bougenvile
Subjective overweight • Diet DM S, VS, FBG,
History of DM (+) more than 10 uncontrolled 2HPPBG,
years. Pharmacology hours
Consumed glibenclamid and • IVFD NS 1400cc/2
metformin hours
Objective • SC Levemir 10 IU
BB 70
TB 160
BMI 27,3

Laboratory
HB 12.9
RBS 308
HbA1C 16,9%
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
5. AKI stage 1 5.1 Volume Pharmacology Pmo :
Mrs. IJ/ 67 yo/ Bogenvile
Subjective
pre renal depletion dt • IVFD NS 1400cc/2 S, VS, UOP
dehydration hours Ur,Cr
nausea and vomiting since 2
days ago, vomit contain with
food and diarrhea

Objective
HR 97
RR 23
Uop 0,3cc/kgbb/hour

Laboratory
Ur/Cr 74,8/1,64
Bun/cr : 20
 PROBLEM ANALISYS

Contact with
COVID-19
Probable COVID-19

Nausea Acute Watery

Hyperglycemia State diarrhea
Vomiting
noniflamatorry
 Risk Factors Analysis
Problem Theory Patient
COVID-19 • Had history of contact or Red Zone area
travelling Contact with confirm case
• Contact with confirm case
• Red area
• Health worker (high risk)
And Severe illness risk
factor :
• Chronic lung disease or
moderate to severe
asthma
• Cardiac disease
• Immunocompromised
• Severe obesity (body
mass index [BMI] of 40 or
higher)
• Diabetes
• Chronic kidney disease
undergoing dialysis
• Liver disease

CDC
Key Message Diagnosis
Key Message Management
Key Message Management
Key Message Management
Condition this morning
• GCS 456
• BP 117/70 mmHg
• HR bpm
• RR 22 tpm
• Tax 36,7 0C