dr.

Vincent

MORNING REPORT
Date : 27/01/2022

Physician in charge
I : dr. Reyhan, dr. Vincent, dr. Bilal, dr. Ida
I A Trainee : dr. Kamal, dr. Rahmat, dr. Christina
II Incovit : dr. Madya
II HCU and Consultation : dr. Satya, dr. Rama
II UGD and Incovit : dr. Camoya, dr. Firman and Dandi
Chief on duty : dr. Angel
Consultant on duty : dr. Achmad Rifai, SpPD
Facilitator : Dr. Djoko Heri Hermanto, SpPD, KHOM
 Summary of Database
Mrs. SA/80 yo/ Ward 24A Jimbaran
Autoanamnesis
Chief Complaint:
Fatigue
History of Present Illness:
- Fatigue since 1 week ago, especially when doing strenuous activities.
- Shortness of breath since 1 month ago, especially during light activities, and sometimes at rest. DOE (+),
cough (-), fever (-).
- Nausea (-), vomiting (-), decreased appetite in the last two months.
- She was Hospitalized since 21/01/2022 at Prima Husada Hospital after being found unconscious at home
and after checking the RBS with result was 13 mg/dL and she regained consciousness after being given IV
dextrose.
- History of Hypertension since 5 years ago and regularly consumes PO Captopril 3x25 mg
- History of DM since 10 years ago but not taking medication regularly, history of taking glibenclamide.
 Summary of Database
Past Medical History:
- There was no remarkable past medical history
Family History:
- There was no history of CKD, DM, and HT in the family
Social History:
- She lived with her daughter and husband, she was a housewife
Review of System:
Fatigue (+)
Shortness of breath (+)
Urination and defecation within normal limit
 Physical Examination
General appearance looked moderately ill Sat O2 97% on NC 2 lpm
GCS 456 UOP: 1500cc/24h ~ 1,56 cc/kgBB/hour
BW: 50 kg: H:150cm: BMI: 22,22 kg/m2

BP 136/72 mmHg PR 75 bpm regular strong RR 22 tpm Tax 36,4oC

Head Conjuctiva Anemic(+), Sclera Icteric (-)
Neck JVP R+5 cmH20

Chest Symmetrical, retraction (-)

Lung Vesicular | Vesicular Rhonkhi : - | - Wheezing : - | -

Vesicular | Vesiculer -|- -|-

Vesicular | Vesiculer +|+ - |-

Cardio Ictus Palpable on ICS VI 2 cm lateral MCL S
LHM ~ ictus, RHM ~ PSL (D) S1 S2 single, regular, murmur (-) gallop (-)

Abdomen Flat, Bowel sounds normal, Soefl, Liver Span 10 cm, Traube's Space Tymphany

Extremities Warm acral, CRT <2”, pitting edema (+/+)

 Laboratory Findings (26/01/2022)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 11.75 4.700 – 11.300 /µL Ureum 203,8 20-40 mg/dL

Hemoglobine 9,20 11,4 - 15,1 g/dl Creatinine 7,18 <1,2 mg/dL

PCV 28,30 38 - 42% Rapid Test Antigen Negative Negative

Thrombocyte 261.000 142.000 – 424.000 /µL Natrium 122 136-145 mmol/L

MCV 77,50 80-93 fl Kalium 4,39 3,5-5,0 mmol/L

MCH 25,20 27-31 pg Chlorida 104 98-106 mmol/L

Eo/Bas/Neu/ 3,0/0,2/77,6/1 0-4/0-1/51-67/ Albumin 2,98 3,5-5,5

Limf/Mon 1,7/7,5 25-33/2-5

RBS 125 80-200 mg/dL

Electrocardiography (26/01/2022)
 Electrocardiography (26/01/2022)
• Sinus Rhythm, HR 64 bpm regular
• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0,04 s
• PR interval : 0,16 s
• QRS complex : 0,10 - 0,12 s
• Q wave : Normal
• T wave : T inverted in lead V1-V6
• QT corrected : 0,428s
• ST segment : Isoelectric

Conclusion : Sinus Rythm 64 bpm with T Inverted in Lead

V2-V6
Chest X-Ray (26/01/2022)
 Chest X-Ray (26/01/2022)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S were dome-shaped
• Phrenico-costalis angle D and S were sharp
• Pulmo: Bronchovesicular pattern was normal, Hilus D/S
were normal. There were no inflitrats/cavity/nodul
• Cor: site N, size and shape enlargement CTR 63% ,
calsification aorta (-),

Conclusion: Cardiomegaly with Congestive pulmonum

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 1. CKD Stage 5 1.1 DKD - USG Non Pharmacology Pmo :
Newly Diagnosed 1.2 HTN Abdomen - Renal Diet 1700 S, VS, UOP/24
Subjective kcal/day, low sodium hr, Uremic
- Fatigue since 1 week <2gr/day, protein 0,6-0,8 Syndrome
ago gr/kgBW/day
- History of DM type 2 - Negative Fluid Balance Pedu
since 10 years, not Education about
routinely consuming Pharmacology the diagnosis
PO Glibenclamide 5 mg - Pro Double Lumen and the
- History of Insertion possibility
Hypertension since 5 - IV Furosemide 3x40 mg causes.
years ago and regularly - Elective HD
consumes PO Captopril Education about
3x25 mg double lumen
access work as a
Objective kidney
- BP 136/72 mmHg replacement,
- UOP : 1,56 cc/kgBW/hr and also
- Ext: Pitting edema (+) consuming low
sodium food
Laboratory 26/01/2022
- RBS : 125 mg/dl
- Ureum : 203,8
- Creatinine : 7,18
- eGFR : 4,904
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 2. HF Stage C FC 2.1 DCM Echocardiogr Non Pharmacology PMo
Subjective IV 2.2 HHD aphy -Low sodium <2gr/day S, VS, SpO2
- Shortness of breath (+) 2.3 CRS type IV -O2 NC 2Lpm
- DOE (+) -Negative fluid balance PEd
- History of DM type 2 since -Bedrest, semifowler position Education about
10 years, not consuming consuming low
antidiabetic drugs Pharmacology sodium food.
regularly - PO Bisoprolol 1x5 mg
- History of Hypertension Educate to take the
since 5 years ago and drug routinely.
regularly consumes PO
Captopril 3x25 mg

Objective
- BP: 136/72 mmHg
- RR: 22 tpm
- SpO2: 97% on NC 2Lpm
- UOP : 1,56 cc/kgBW/hr
- Cor: Ictus cordis palpable
at ICS VI 2cm lateral MCL S
- Pulmo: Rhonki +/+ basal

ECG 26/01/2022
Sinus Rhythm 64bpm dengan T
Inverted di Lead V2-V6

CXR 26/01/2022
Cardiomegaly with congestive
pulmonum
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 3. Anemia 5.1 Related - SI, Non Pharmacology Pmo :
Hipochromic Renal TIBC, - S, VS, Oxygen
Subjective Microciter 5.2 Fe Saturati hunger
- Fatigue since 1 week ago Deficiency on Pharmacology
- Decreased of appetite in Transfer - Treat Underlying Disease Pedu
the last 2 months rin, Education about
Ferritin the diagnosis
Objective Serum and the
- H/N : Conjunctiva Anemic (+) possibility
causes of
Laboratory 26/01/2022 anemia.
- Hb : 9,20
- MCV/MCH : 77,50/25,20
- Ur/Cr : 203,8/7,18
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 4. Hypertension - - Non Pharmacology PMo
on Treatment -Low sodium <2gr/day S, VS
Subjective
- History of PEd
Hypertension since 5 Pharmacology Education about
years ago and regularly -PO Captopril 3x25mg consuming low
consumes PO Captopril -PO Amlodipine 1x10mg sodium food.
3x25 mg
Educate to take
Objective the drug
- BP: 136/72 mmHg routinely.

Educate about
the disease and
its complication.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 5. DM type 2 - - Non Pharmacology Pmo :
Normoweight • Diet DM 1700 kkal/day S, VS,
Subjective Normoglycemia based on BROCA, 55% FBG/FG2PP
-History of DM type 2 since Carbohydrate, 25% Fat,
10 years, not routinely 20% Protein Pedu:
consuming PO Educate about
Glibenclamide 5 mg Pharmacology the
- Insulin (waiting for FG importance of
Objective and FG2PP) routinely
BW: 50kg, H: 150cm taking
BMI : 22,22 (Normoweight) medicine.

Laboratory 26/01/2022 Educate about

- RBS POCT : 125 mg/dl the
complication
of DM.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 6. Hiponatremia 6.1 Dilutional - Non Pharmacology PMo
Hiperosmolar - Diet 1700kcal/day S, VS, SE every 3
Subjective Hipervolemia days
- Pharmacology
- PEd
Objective Education about
- BP: 136/72 mmHg the etiology of
current
Laboratory 26/01/2022 condition and its
- Natrium : 122 complication
- Osmolarity : 309,64
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SA/80 yo/ Ward 24A 7. 7.1 Renal - Non Pharmacology PMo
Moderate Loss   - Diet 1700kcal/day extra S, VS, Albumin
Subjective Hypoalbum 7.2 Low Intake Protein
- Edema in lower extremities inemia   PEd
- Decreased of apetite Pharmacology Education about
- Treat underlying disease the etiology of
Objective current
- Ext inferior : pitting edema condition and its
(+) complication
Educate about
Laboratory 26/01/2022 consuming
- Albumin : 2,98 more protein
 Problem Analysis

Diabetes Mellitus HT Uncontrolled

Renal
Activation of Ischemia and
Hemodynamic HHD
RAAS Inflammation
Changes

Increased
Renovascular DCM
resistance

HF St. C
CKD Stage 5 CRS type 4
Hypoalbuminemia
FC IV

Hyponatremia
Anemia Renal
 Risk Factor Analysis
Problem Theory Patient

Chronic Kidney Disease
Offer testing for CKD using eGFR HYPERTENSION
creatinine and ACR to people with any DIABETES
of the following Risk
Factors :
-Diabetes
-Hypertension
-acute kidney injury
-Cardiovascular disease (ischaemic
heart disease, chronic heart failure,
peripheral vascular disease or cerebral
vascular disease)
-Structural renal tract disease,
recurrent renal calculi or prostatic
hypertrophy
-Family history of end-stage kidney
disease (GFR category G5) or
hereditary kidney disease
-Opportunistic detection of haematuria

From :
1. NICE GUIDELINES, 2015. Chronic kidney disease in adults: assessment and management
 Key Message Pathophysiology

From :
1. Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron deficiency in chronic kidney disease: updates on
pathophysiology, diagnosis, and treatment. Journal of the American Society of Nephrology. 2020 Mar 1;31(3):456-68
 Key Message Diagnosis

From :
1. Levin A, Stevens PE, Bilous RW, Coresh J, De Francisco AL, De Jong PE, Griffith KE, Hemmelgarn BR, Iseki K, Lamb EJ, Levey
AS. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the
evaluation and management of chronic kidney disease. Kidney international supplements. 2013 Jan 1;3(1):1-50.
 Management Analysis
Problem Theory Patient

CKD + HT ● Low sodium diet < 2 gram/

day
● Protein 0,6- 0,8 g/KgBB/day
ESC,2018 ● PO Captopril 3x25mg
● PO Amlodipine 1x10 mg
● RenaL replacement
KDIGO,2021

From :
1. Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW. KDIGO 2021 clinical practice guideline for the
management of blood pressure in chronic kidney disease. Kidney International. 2021 Mar 1;99(3):S1-87.
2. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, De Simone G, Dominiczak A, Kahan T. 2018 ESC/ESH Guidelines for the
management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society
of Hypertension (ESH). European heart journal. 2018 Sep 1;39(33):3021-104.
 Key Message Social

• The patient’s family should be educated regarding the

irreversibility of the patient’s overall condition, mainly the
CKD and Diabetes.
• The care at home is just as important as the caregiver at
the hospital, so it should an utmost importance for the
patient’s family to understand the patient’s overall
condition.
• Patient need family support
 Condition this morning

• GCS 456, compos mentis

• BP 140/95 mmHg
• HR 90 bpm
• RR 20 tpm
• Tax 36,3oC
 Prognosis

• Ad vitam : dubia
• Ad functionam : dubia
• Ad sanationam : dubia
THANK YOU