MORNING REPORT

Wednesday, June 23rd 2021

Physician in charge
I : dr. Amang, dr. Satya, dr. Jauhar (cardio)
II CVCU : dr. Camo
II HCU : dr. Ika
II HCU Incovit : dt. Sandi
II UGD : dr. Angel, dr. Reta, dr. Rezdy (incovit)
Chief on duty : dt. Arde
Consultant on duty : dr. Heri Sutanto Sp,PD
RESUME
Admission Discharge MedCon Pass away Remaining Total
5 1 2 0 2 8

20%

Admission
Discharge
50% Medcon
Pass away
Remaining
20%

10%
 PROBLEM ORIENTED MEDICAL RECORD
Cue and Clue Problem List and Planning War
Initial Diagnosis d
Identity: P2 Incovit / Mr. S/ 64 Y.o Emergency Planning Diagnosis: ER
Primary survey : 1. Mild ARDS - Inco
Circulation: warm, Airway: patent; Breathing: spontaneous vit
Secondary survey : Urgency Planning therapy
Chief complaint : Shortness of breath 2. Confirmed case - Diet 1700 kcal/day extra potassium
Shortness of breath since one day before admission, DOE (-), Orthopneu (-), PND covid 19 severe - O2 NRBM 8-12 lpm
(-). He experienced productive cough since four days ago, it accompanied with - IVFD NS 1000 cc/24 hour
loss of smell-sensation. History of chest pain happened two days ago and he had Non Urgency - IV Azithromycin 1x500 mg
3. CCS PTP 27% - IV drip Vitamin C 200 mg + NS 100 cc in 1
undergone heart catheterization in 2003. Diagnosed as covid (-), covid vaccine 4. Mild Hypokalemia dt hour/8 hour
(-), history of contact with covid19 patient (-). Medication history: SC heparin, IV Low intake - IV dexamethasone 1x6 mg
Dexamethasone, PO Vitamin D3, PO Becomzet, PO Aspilet, PO Rosuvastatin, PO 5. Thrombocytopenia - IV Paracetamol 3x1 gram
Paracetamol, PO Favipiravir. He used to work as employee in private work and related to covid 19 - IV NAC 5 gram/72 hour
got to meet other people. 6. Geriatric problems - IV vitamin B12 1 amp/day
(Infection, inanition) - SC Enoxaparin 2x60 mg
Objective :GA: looked moderately ill, GCS 456; BP: 138/64 mmHg; PR: 89 bpm; - PO Vitamin D3 1x5000 unit
- PO Atorvastatin 0-40 mg
RR : 23-24 tpm; Tax: 36,3 °C; SaO2 : 85-86% on NC 4 lpm-> 99% NRBM 10 lpm; - PO Aspilet 1x80 mg
Weight : 65 kg/ TB 165 cm, BMI : 23,9, normoweight, Physical examination - PO Favipiravir 2x1600 mg  2x600 mg
didn’t performed - PO Zinc 3x20 mg
- Plan to consult to Cardiology department
Laboratory RSSA Lab 22/6/21: Na/K/Cl 133/3.26/103 mmol/L/ Hb 15 / WBC
3900 / PLT 141000/ MCV 79.10/MCH 28.20/ PPT 10.30 (11.4) / INR 0.99 / APTT Planning Monitoring:
35.40 (25,9)/ D-dimer 2.47 / OT/PT 82/45 / HbA1c 6.60% / Ur/Cr 25.8/0.83 / CRP S, VS, SpO2, RT-PCR swab covid 19
15.65 / Procalcitonin 0.14 / GDS 195 / D-dimer 2.47 / BGA with NRBM 10 lpm pH
7.44 / pCO2 25 / pO2 177.8 / HCO3 17 / BE -7.4 / SaO2 98.7% / Acid lactate 1.4
mmol/L / P/F ratio 222 (mild ARDS), FiO2 needed : 67,28%, PADUA Score : 8,
Improve score : 4 Barthel index : 80 MNA : 11
Swab Antigen covid 19 20/6/21 RSSA : positive, CXR 20/06/21: Pneumonia
typical ec. Viruses, ECG : sinus rhythm 75 bpm

References:
PAPDI 4th ed,
UpToDate 2020