MORNING REPORT

13th January 2020

PHYSICIAN IN CHARGE :

IA : dr. Ani, dr. Dea, dr. Helsa, dr. Angel, dr. Firdha
II CVCU : dr. Ajeng
II HCU : dr. Kasman
II ER : dr. Jefri, dr. Hana, dr. Reizal
Chief : dr. Bunga
Consultant : dr. Perdana Aditya, SpPD
Facilitator : dr. Nursamsu, SpPD-KGH
 RESUME
Admission Discharge MedCon Passed away Remaining Total
3 4 4 1 12 24

Patient's Status

Admission Discharge MedCon Passed Away Remaining

 PROBLEM ORIENTED MEDICAL RECORD
Cue and Clue Problem List and Planning War
Initial Diagnosis d
Medical consultation from NS department asking for DM type 2 Emergency: Planning Diagnosis: ER
management - -
Identity: P1/ Mrs. W / 64 y.o Neuro department
Urgency: - Line 2 drip Nicardipine 5-15mg /
Primary survey : 1. Mild KAD precipitating hours
Circulation: warm, Airway: patent Breathing: spontan factor poor compliance Internal medicine department
Anamnesis: 2. CVA IVH + SDH -Line 1 NS rehydration 1000cc-->
Patient with CVA IVH + SDH planned for VP shunt (waiting for family Hypokalemia correction KCL 25
approval). Patient with DM since 5 years ago, medication: Non Urgency: meq in NS 500cc in 3 hours
glibenclamide 1x5mg. Last time took medication was 2 months ago 3. CKD st 4 -Drip insulin 2IU/hours, check RBS
because She took herbal drink and said that Her glucose was normal, 3.1 DKD per hour
3.2 HT Nephrosclerosis -If RBS in third hour is 250-300
HT was known 5 years ago, didn't take medication 4. HT st II uncontrolled then bolus SC rapid insulin 4IU, if
5. Anemia HM RBS in third hour is >300 then
Objective : looked severely ill; GCS 223; BP 153/70 mmHg; HR 75 bpm; 5.1 Chronic disease bolus rapid insulin 6IU
RR 20 bpm; Tax 36.7°C; SpO2 99% with NRBM lpm, BW: 50kg 6. Mild hypokalemia -Suggest to insert CVC to enable
H/N: anemic (+), isocor; C/p: ictus palpable in MCL ICS VI; Ext: 6.1 Low intake hypokalemia correction more
lateralization to sinistra; Pathologic reflex: Babinski -/+, chaddock -/+, 7. DM type 2 on OAD adequate
-Check SE and BGA and keton per
oppenheim -/+, gonda -/+ 4 hours
Lab 13/1/20: Hb 8.5g/dl; MCV/MCH 69.3/21.2fl/pg; WBC 14.790u/L -Patient will be join care with
DC 0/0.1/70.9/17.4/11.6 %; PLT 373.000u/L; OT/PT 17/10U/L endocrinology division
GDS 395mg/dl; Ur/Cr    65.9/2.19mg/dl ; eGFR 20ml/min; Na/K/Cl
144/3.03/112mmol/L; RBS 15.00: 388mg/dl; Keton: 3.3; BGA
13/1/2020: ph 7.30/ PCO2 31.9 / PO2 255.1 / HCO3 15.7 / BE -10.9-->
asidosis metabolic partially compensated anion gap: 21.3; Urinalisis
12-1-2020: Protein 2+, glucose 2+, keton 1+
CXR: Normal
ECG: Sinus HR 75 bpm, LVH

References: PAPDI
Ny. Wila
Ny. Wila
 PROBLEM ORIENTED MEDICAL RECORD
Cue and Clue Problem List and Planning War
Initial Diagnosis d
Identity: P2/ Mrs. H/ 59 y.o Emergency: Planning Diagnosis: ER
Primary survey : - Urine culture + AB sensitivity
Circulation: warm, Airway: patent Breathing: spontan
Urgency: Internal medicine department
Secondary survey : 1. DOC Non pharmacology:
Chief complaint : Fever 1.1 Mild KAD Bed rest
-fever since 2 days before admission, nausea + vomitting -, headache + 2. Mild KAD precipitating Fasting temporary
-non productive cough since 2 days ago factor poor compliance
-DM since 1 year ago, didn't take medication, HT - Pharmacology
-defecation and urination were normal Non urgency O2 NC 4 lpm
-referred from other hospital, medication: ceftriaxone 2x1gr, levemir 1. CKD st 3 Line 1 NS rehydration 1000cc-->
1.1 DKD NS + KCL 25 meq 20 tpm
1x20IU 2. DM type 2 Line 2 Drip Insulin 5IU/ hour
uncontrolled IV ceftriaxone 2x1 gr
Objective : looked moderately ill; GCS 446; BP 127/76 mmHg; HR 120 3. Complicated lower UTI IV ranitidine 2x1 amp
bpm; RR 22 bpm; Tax 37°C; SpO2 94% RA  99% NC 4 lpm, BW: 55kg 4. Nausea IV metoclopramide 3x10mg
Abd: soefl, bowel sound +, epigastric pain + 4.1 Related to KAD PO PCT 3x500mg
4.2 Related to UTI
4.3 Diabetic Planning Monitoring:
Lab 13/1/20: Hb 15.3g/dl; MCV/MCH 87.7/33.5fl/pg; WBC gastroparese S, VS, RBS per hour, SE and BGA
15.300u/L and keton per 4 hours
Diff Count 1/0/57/27/12 %; PLT 164.000u/L; OT/PT 61/36U/L; Ur/Cr   
33.6/1.7mg/dl; eGFR: 31ml/min; Na/K/Cl 120/3.98/93mmol/L
UL 40x: RBC: 51.6LPB (eumorphic 60%), WBC 13.8 LPB, nitrit positive
BGA 14-1-2020: ph 7.27 / PCO2 25 / PO2 77.7 / HCO3 11.7 / BE -15.3 /
anion gap: 15.3--> metabolic acidosis partially compensated
RBS 23.00: 508mg/dl--> 415mg/dl--> 399mg/dl 285mg/dl; Keton
23.00: 3.4
CXR: Normal
ECG: Sinus tachycardia HR 130 bpm, slow progression of R wave

References: PAPDI
Ny. Hasimah
Ny. Hasimah
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and Wa
Cue and Clue Planning
Initial Diagnosis rd
Identity : Mrs H/ 62y.o/ P2 Emergency: Planning Diagnosis:
Primary survey : Rencana Endoskopi if stable, Cek
Urgency HCV RNA
Circulation: warm, Airway: patent , Breathing: spontan Planning Therapy
1. Melena
Secondary survey : Chief complaint : Black-tarry stools 1.1 Variceal bleeding dt - Bedrest
Subjective : Black-tarry stools since 5 days, soft consistency, fisghy - Fasting
rupture varices esofagusNon - NGT, GL/8jours --> 3x clear -->
odor. Bloody vomiting (-). Never before. Abdominal enlargement Urgency: start fluid diet 6x200 cc
since 1 month, diagnosed with liver disease at previous 2. Anemia NN - IVFD NS rehidrasi 1000 cc in 2
hospital.Alcoholic (-), consume potion (-), history 'sakit kuning' (-), 2.1 dt blood loss hours --> NS:D10 2:1 1500
history bloody vomiting at family (-). She work as a housewife 3. Sirosis hepatis post cc/24hourx
Objective : Looked moderately ill. GCS: 456. BP: 140/90. HR: necrotic hepatitis C infection - IV Ceftriaxone 1x1 gr
Child Pugh B - IV Metoclopramide 3x10 mg
90bpm. RR: 22tpm. Term : 37°C. SaO2: 98% NC 4. Hepatitis C infection - IV Lansoprazole 2x30 mg
h/n : conj anemis (+). Cor : S1 S2 S. Pulmo : Vesikular +/+. Abd : BU 5. Hypoalbuminemia - Drip Somatostatin 250 mcg/hours
normal,liver span sulit dievaluasi, Traube's space dullness, nyeri 5.1 decreased of liver —> until melena improved or
tekan (-), undulasi (+). Ext : akral hangat, edema +/+. RT : TSA production 72hours
- Urine cathether --> px refused
normal, mukosa licin, melena (+), mass (-) 6. Geriatric problem - Endoskopi if stable
Laboratorium : DL 9.6/12.190/28.5%/277.000. Mcv/Mch (inanition, instability) - PO Spironolakton 1x100 mg -->
88.50/29.80. Diff count 1.7/0.3/78.3/13.2/6.5%. Ppt 14.7/10.9. INR posponed
- PO Laktulosa 3x30 cc
1.45. Aptt 31.00/24.3. Bilirubin TDI 1.41/1.33/0.08. OT 254/PT 67. - PO Propranolol 2x10 mg -->
Albumin 2.47. Globulin 4,39. GDS 66.Ur/Cr 77.3/2.05.HBsAg non postponed
reaktif. Anti HCV reaktif - Ascited evacuation
ECG : Sinus rhytm, HR 90 bpm - Daclatasvir, Sofosbuvir waiting for
HCV RNA
CXR : Cor pulmo dalam batas normal Planning Monitoring
USG Abd : chronic liver disease —> sirosis hati, riight lobe S, VS, UOP, melena, DL
hipoechoic nodul susp hemangioma DD FNH degenerasi maligna,
Susp trombus vena porta, asites, sludge GB
CXR Mrs Hamiyeh/ 62 yo
ECG Mrs Hamiyeh/ 62 yo
USG Mrs Hamiyeh/ 62 yo
Mrs Hamiyeh/ 62 yo
 Problem List and
PROBLEM ORIENTED
Cue and Clue MEDICAL RECORD
Initial Diagnosis
Planning W

Medical Consultation from Digestive Surgery EMERGENCY : PLANNING DIAGNOSIS : E

Department Asking management of AKI 1. Peritonitis generalisata - BGA, UL, ECG, Abdominal USG R
Identity : P1 / Ms. Anita/ 29 yo - Blood & Sputum Culture, AB sensitivity test
PRIMARY SURVEY : A : Paten / B : Spontan / C : Warm URGENCY : Treatment from Digextive :
SECONDARY SURVEY: 2. Septic condition dt - Ivfd NS 20 tpm
Chief Complaint : Abdominal Pain peritonitis generalisata - Iv Santagesic 3x1 amp
Pain in all area of Abdominal since 3 day ago & - Iv Ranitidine 2x1 amp
worsening since 1 days ago accompanied with NON URGENCY Treatment From Internal Medicine:
Abdominal enkargement (+), Fever (+), Nausea 3. Anemia HM Non-farmakologis
Vomitting (+).She didn’t Defecate and flatus since 1 days 3.1 defisiensi Fe Bed rest semi fowler
ago. Cough since 5 days ago, Shortness of breath (+), 3.2 blood loss O2 NRBM 10 lpm
fatigue (+). She just got birth 1 week ago with 4. Hypoalbuminemia NGT Inserted  Decompretion  Fasting
spontaneous delivery & the baby was alive. HT(-), DM (-) 4.1 hypercathabolic Urine Catheter inserted
Physical Examination state Farmakologis
Looked severely ill, GCS 456. BP 105/60 mmHg, HR 108 4.2 renal loss - Ivfd NS 1500 cc over 3 H --> 1500 cc/24H
bpm, RR 28x/minute, Tax 36.5°C. SaO2 98% on 8 lpm 5. Acute cough + infiltrate - IV Ceftriaxone 2x1 gr
NRBM R upper Dextra lung - IV Levofloxacin 1x750 mg --> 1x500 mg/48 jam
H : An Conj(-), icteric (-). Thorax : RH + upper medial 5.1 CAP - IV Lansoprazole 1x30 mg
dextra, Abd : distended(+), Decreased of BS, defans 6. AKI st III - Transfusion of Albumin 20% 100 cc up to albumin
muskuler (+), Pain in all area(+). Ext : edema -|- 6.1 renal > 2.5
Laboratory : Hb 10.7 MCV/MCH 52.5/ 16,7 / Leu 25.330/ hypoperfusion dt septic - HD if Indicate (anuria, overload, asidosis metabolik
33.6% /239.000. Diff Count 0.1/0,1/ *92*/1,3/6.6. RBS condition severe, hiperkalemia refrakter, uremic syndrome)
103. PPT 14.9 (K10.9), INR 1.47, APTT 37.3 (K24.3).
Albumin 1.69 PLANNING MONITORING
S, VS, BUOP, Ur/Cr

Patient will be joint care with Nephrology Division

References:
EIMED PAPDI
 Problem List and
PROBLEM
Cue and Clue ORIENTED MEDICAL RECORD
Initial Diagnosis
Planning W

Medical Consultation from Cardiology Department Asking management and EMERGENCY : PLANNING DIAGNOSIS : - E
consideration to take over patien with Septic Shock & Ca Tiroid 1. Shock condition Treatment from Cardiology : R
Identity : P1 / Mr. Nor Sofi’i/ 50 yo 1.1 Hypovolemic - Rehydration NS 1000cc  20
PRIMARY SURVEY : A : Paten / B : Spontan / C : Cold shock tpm
SECONDARY SURVEY: 1.2 Septic shock - O2 jacksone reese  Refused
Chief Complaint : Decreased of Consciousness 2. Respiratory intubation
DOC since 1 day ago, Gradually onset. Firstly he complaint of shortness of failure type 2 - Drip NE 0.05-2 mcg/kgbb/minute
breath then got apnea because of heart attack. SOB since 1 month ago, URGENCY : - IV. Omeprazole 1x40 mg
intermittenly, worsening since 2 days ago. Fever (-), Cough (+). Lump in the neck 1.1 DOC Treatment From Internal
since 10 years ago & got bigger day by day. Pain(-), Headache (+). Diagnosed 1.1 Hypoxic Medicine:
with Ca Tiroid since 2 weeks ago, routinely controll at oncology RSSA & plan to encephalopathy - Equal fluid Balance
perform Radioterapi (29/1/2020). HT(-), DM(-). Patient reffered to RSSA due to 1.2 Septic - NGT Inserted -> Fluid Diet
post Cardiac Arrest enchepalopathy 6x200cc
Physical Examination NON URGENCY - Hypoglicemia Correction -> D40%
Looked severely ill, GCS 111 BP 80/56 mmHg on drip NE, HR 104 bpm 1. Ca thyroid 3 flask -> Check POCT
RR 24x/minute, Tax 36.9°C SaO2 93% on JR , UOP 300CC/10 H, IVC : Collaps T4N0M0 - Line 1 : Drip NE 0.05-2
H/N : Mass at reg colli 12 cm, fixed. Pulmo : Bronchial pattern Breathing, Rh 2. Post cardiac mcg/kgbb/minute
(-/-), Wh (-/-). Eks : Cold, edema (-/-). Laboratory : RBG 44  136, Hb 16.4 arrest - Line 2 : IVFD NS 20 tpm
MCV/MCH 90.8/ 29.6 / Leu 25.540/ Hct 50.3%/ Plt 417.000. DC 3. Leukositosis - Line 3 : IVFD D10% maintanance
0.1/0.2/86.4/9.1/4.2%. PPT 11.1, APTT 32.6, INR 1.07, Fibrinogen 375.6, D- 3.1 Paraneoplastik 10 tpm
dimer 4.54(<0.5). SGOT/ SGPT 126/ 392, Albumin 3.41, RBG 90 mg/dl. Ur/Cr 4. Increase - Management of Ca thyroid
37.5/ 1.1  59.9/ 1.74, BUN/Cr : 16.11 renal. Na/K/Cl : 138/ 4.4/110, Troponin I transaminase acording to Oncology Department
: 2.3(<0.1), CK-MB : 41 (7-25), Lactid acid 3.2. TSH 0.81 (0.27-4.2), FT4 17.24 4.1 reactive post - Educate about Patient condition
(10.6-19.4). BGA : ph 6.99/ pCO2 103.3/ pO2 107.1, HCO3 25.3, BE -6.3, sat O2 MODS dt cardiac and Prognostic
93.6% (Acute Acidosis Respiratorik). Urinalysis : protein 1+, lekosit trace, blood arrest PLANNING MONITORING
3+. 40x: eri 33.8 lpb (eumorfik 79%), lekosit 8.1 lpb, Bacteria 1342.1x10 3. ECG : 5. AKI stage 1 S, VS, UOP, Ur/Cr, OT/PT, BGA, RBS
Sinus Tachicardia HR 125 bpm. USG TIROID : multiple nodul mixed solid 5.1 volume Patient will not be joint care with
isoechoic-kistik-spongiform thyroid bilateral spread to isthmus, midly depletion internal medicine department
suspicious, TIRADS . FNAB thyroid : anaplastik carcinoma thyroid. CXR : 6. Hypoglikemia
Metastase process (-), mass at regio colli

References:
EIMED PAPDI
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and Wa
Cue and Clue Planning
Initial Diagnosis rd
Identity : Mr S/ 72 y.o/ P2 Emergency: Planning Diagnosis:
Primary survey : 1. SOB BGA, procalcitonin, lactid acid, CBC,
1.1 Pneumonia CAP albumin, CT-scan thorax
Circulation: warm, Airway: patent , Breathing: spontan Planning Therapy
1.2 Lung tumor
Secondary survey : Chief complaint : SOB Urgency - Bedrest
Subjective : Continuous SOB since 2months, increased since 5days. - O2 nasal 4 lpm
2. Sepsis condition - Soft diet1800kkal/day
Didn't affected with activities. Intermittent cough (+), sputum (-). 2.1 CAP - IV. Omeprazole 1x40 mg
Low grade fever (+). Decreased bodyweight (+). Admitted for 4days Non Urgency: - Po. Paracetamol 3x500 mg (if
at previous hospital, received 1 pack RBC transfussion, Ceftriaxone 3. Moderate hypokalemia needed)
and Metronidazole. DM (-), HT (-), Lung TB (-). Smoker (+) since 3.1 Low intake - Nebul salbutamol/ 8 hours
young 4. Hypoalbuminemia severe Planning Monitoring
4.1 Low intake S, VS
Objective : GCS 456. BP 108/58 mmhg. N 110x. RR 26xu. Tax 36.7. 5. Anemia NN
SpO2 99% nasal. UOP 100cc/hours. BW 70 kg, H 170 cm, IMT 24.2 5.1 Chronic disease
MNA score: 11 (at risk of malnutrition) 6. Geriatric problem
Barthel index: 65 (minimally dependent) (infection, immobilization)
H/N : conj anemis (+). Pulmo : Rh -/+ medial S, Wh +/+ medial D/S.
Abd Soefl BS N. Ext : edema +/+ arm and kegs
Laboratorium : DL 8/ 32.700/ 24.9%/ 213.000. MCV/MCH 81/ 26.1.
DC 0/0/89/5/5%. SGOT/SGPT 11/8. Ur/Cr 12.3/ 0.2. GDS 121. Na/
K : 128/ 2.6. Albumin 1.96 —> 1.64. UL : DBN. BGA : BGA : ph 7.39,
pCO2 40.9, pO2 92.3, HCO3 25.1, BE -0.1, sat O2 97.1%
ECG : sinus takikardia, HR 110x/m
CXR : Paracardial S consolidation suspek pneumonia dd lung mass
CXR Mr Supiin
ECG Mr Supiin