MORNING REPORT

Date : 2 February 2018

Physician in charge
I : dr. Jefri, dr. Hana, dr. Galih, dr. Yudi (Cardio)
II CVCU: dr. Roni
II HCU : dr. Bunga
II UGD : dr. Norma, dr. Meti
Chief on duty : dr. Kathy
Consultant on duty : dr. Herwindo Pudjo, SpPD
 Summary of Database
Mr S/ 58yo/ward 25. Bed 2.7
Autoanamnesa
Chief Complaint: General Weakness
History of Present Illness:
Patient came with general of weakness since 3 days ago. He couldn’t do activity like usual. Usually he could work for 3 hours a day
but now he only worked only about 2 hours and it was only cutting the grass. These condition had been happening more than a year and
finally a year ago, due to this unsolved problem he went to doctor and he was diagnosed with ”jantung dan paru bengkak” and there
was something wrong with the kidney despite of his normal defecation and urination. He usually defecated 1 time with normal
consistency. He drank 2L per day and he urinated very much. Due to this problem then he was referred to RSSA.
Patient had a routine HD twice a week every Monday and Thursday since a year ago and finally 6 months ago he was diagnosed
multiple myeloma. He got treated with regimen chemotherapy and octabone 1x600mg, and the next chemotherapy schedule is
6/2/2018.
He never had hypertension and diabetes mellitus. His highest blood pressure was 120/80.. He took allopurinol everyday. There
was no allergy.
 Summary of Database
Past Medical History:
Patient stated that he had sudden onset broken thigh, there was no trauma happened and it was 1 year ago.. He also said that he
could sit since 6 months ago but now he could sit and even walked by himself
Family History:
He also denied same disease in closest relatives
Social History:
Patient worked as a farmer with 1 wife and 2 children. Patient had a history of smoking 24 cigarettes everyday for more than 20 years
Review of System:
-
 Physical Examination
General appearance look moderately ill Sat O2 98%onroom air
GCS 456 VAS 0/10
BP 120/80 mmHg PR 80 bpm regular strong RR 20 tpm Tax 36oC
Head Conjuctiva Anemic (+), Sclera Icteric (-),
Neck JVP R+ 0 cmH20
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 8 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany
Extremities Edema (-), pale (-), MMT 5 | 5 , uremic frost (+)
5|5
 Laboratory Findings (2/2/2018)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 6960 4.700 – 11.300 /µL Ureum 50.1 20-40 mg/dL

Hemoglobine 5.4 11,4 - 15,1 g/dl Creatinine 5.29 <1,2 mg/dL

PCV 16.7 38 - 42% eGFR 11ml/min

Thrombocyte 245.000 142.000 – Natrium 145 136-145 mmol/L

424.000 /µL

MCV 96 80-93 fl Kalium 3.63 3,5-5,0 mmol/L

MCH 31 27-31 pg Chlorida 111 98-106 mmol/L

Eo/Bas/Neu/ 4.3/0.0/67. 0-4/0-1/51-67/ Calcium 9.1 7,6-11,0 mg/ml

Limf/Mon 8/15.4/12. 25-33/2-5
5% Phospor 2.5 2.7 – 4.5 mg/dL

SGOT - 0-40 U/L

SGPT - 0-41 U/L

Albumin 3.70 3.5-5.5 g/dL

 Urinalysis (02/02/2018)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity 10 x
Color Yellow Epithelia 0,4 ≤1
pH 8,0 4.5 – 8.0 Cylinder -

1.015 1.005 – 1.030

Hyaline -
SG
Glucose trace negative Granular
Protein 2+ negative Other
Keton Negative negative

Bilirubin Negative negative 40 x

Urobilinogen Negative negative Erythrocyte 0,4 ≤3
Nitrite Negative negative Leukocyte 2,2 ≤5
Leukocyte Negative negative Crystal
Erythrocyte Trace-Intact negative Bacteria 22,7x103 ≤23 x 103/ml
Other
Electrocardiography (2/2/2018)
 Electrocardiography (2/2/2018)

• Sinus rhythm, HR 80 bpm

• Frontal Axis : Normal
• Horizontal Axis : CWR
• PR interval : 0,16 sec
• QRS complex : 0.08 sec
• QT interval : 0.36 sec

Conclusion : Sinus rhythm HR 80 bpm with axis CWR

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Anemia 1.1 Multiple -2 Non- Pharmacologic CBC post
Mr S/ 58yo/ward 25
Gravis Myeloma Microglobul -Bed rest transfusion,
Subjective 1.2 Macrocytic in, BMP -IV plug transfusion
General weakness (+), HD Megaloblastic -Renal diet, low salt <2gr, reaction,
routine, sudden onset of
broken thigh (+) had been Anemia low protein KIE about
0,8-1,0/kgBB/day the disease
diagnosed Multiple Pharmacologic and
Myeloma -Folic acid 1x1 PO prognosis
Objective
Conjunctiva anemis (+) -Vitamin B6/B12 3x1
Laboratory -Transfusion PRC 2 lb/day
until Hb> 8g/dL
Hb: 5,4g/dL
MCV/MCH: 91/31
Ur/cr: 50,1/5,29mg/dl
eGFR: 11ml/min
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. CKD St V on 2.1 Due to - Non- Pharmacologic Subjective,
Mr S/ 58yo/ward 25
routine HD Multiple -Bed rest Objective,
Subjective myeloma -IV plug urine
Had routine HD (+), general - Renal diet, low salt <2gr, ouput, KIE
weakness, hypertension (-),
diabetes mellitus (-) low protein to get AV
0,8-1,0/kgBB/day shunt
Objective Pharmacologic
BP: 120/80mmHg -HD as scheduled
Anemic conjunctive (+)
Uremic frost (+)
Laboratory
Hb: 5,4g/dL
MCV/MCH: 91/31
Ur/Cr: 50,1/5,29mg/dl
eGFR: 11ml/min
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Multiple - - Non- Pharmacologic KIE about
Mr S/ 58yo/ward 25
Myeloma -Bed rest the disease
Subjective -IV plug and
General weakness (+), HD -Renal diet, low salt <2gr, prognosis
routine, sudden onset of
broken thigh (+) had been low protein
0,8-1,0/kgBB/day
diagnosed Multiple Pharmacologic
Myeloma --Chemotherapy as
Objective
Conjunctiva anemis (+) scheduled (Octabone
Laboratory 1x600mg)
Hb: 5,4g/dL
MCV/MCH: 91/31
Ur/cr: 50,1/5,29mg/dl
eGFR: 11ml/min
 Problem Analysis

Multiple Myeloma

Anemia Gravis

CKD St V on routine HD
 Risk Factors Analysis

Problem Theory Patient

Multiple Myeloma • Male

Pabdi 6th Edition

 Key Message Pathophysiology

Multiple myeloma is a cancer that forms in plasma cells. Plasma cells

are white blood cells found in bone marrow. Plasma cells are a key
part of the immune system. They make antibodies that fight
infection.
When plasma cells become cancerous, they produce a protein that
grows quickly and takes over the bone marrow, blocking healthy cells
from doing their job. The cancerous cells grow into bone tumors
called plasmacytomas. When there’s just one tumor formed in the
bone, the condition is called a myeloma. If multiple tumors exist, this
is called multiple myeloma.
Key Message Diagnosis

Pabdi 6th Edition

 Management Analysis
Problem Theory Patient

Chemotherapy and
Multiple Octabone 1x600mg
Myeloma

Pabdi 6th Edition

 Key Message Social

• Support from famly still neded to continue the routine hemodialysa

• Patient will be educated about double lumen as first access to
hemodylisa and the educate about AV shunt.
• Multiple myeloma can’t be complete recovery but it can be
controlled.
 CONDITION THIS MORNING

• GCS : 456
• BP : 120/70 mmHg
• HR : 84 bpm
• RR : 20 tpm
• Tax : 36,8oC
 Prognosis

• Ad vitam : bonam
• Ad functionam : bonam
• Ad sanationam : bonam
 THANK YOU VERY MUCH
FOR YOUR KIND ATTENTION