MORNING REPORT

Date : Monday, 2nd November 2020

Physician in charge
I : dr. Sandi, dr. Alfan, dr. Pundi
II CVCU : dr. Akbar
II HCU : dr. Helsa, dr. Ketut
II UGD : dr. Pandu, dr. Angel, dr. Ferdi
Chief on duty : dr. Tia
Consultant on duty : dr. Sri Sunarti, Sp.PD-KGer
Facilitator : dr. Sri Sunarti, Sp.PD-KGer
 Summary of Database
Mr. FW/ 61 y.o/ intensive ward
Autoanamnesa
Chief Complaint: Black tarry stool

History of Present Illness:

Patient complained about black tarry stool since 2 days ago, followed by coffee
ground vomiting. Black tarry stool about 3 times/day about 50cc each time, and
coffee ground vomiting 1 time/day about 200 cc each vomit. The patient often came
to hospital due to black tarry stool and coffee ground vomiting.
He had diagnosed with Cirrhosis Hepatis since 8 years ago, with history of
Hepatitis C infection. He didn’t take any medication related to Hepatitis C infection.
He also had diagnosed with Diabetes Mellitus since 8 years ago and routinely
consumed glimepiride 4 mg once daily.
 Summary of Database
Past Medical History:
History of Lung TB in 2012, got treatment of TB for 6 months and resolved.

Family History:
His mother had history of Diabetes Mellitus.

Social History:
- He worked as a mechanical engineer.
- He lived with his wife and his daughter.
- He was a smoker since the age of 12, around 12 bars/day. Alcohol consumption was denied.

Review of System:
Fever (-), cough (-), decreased of body weight (-)
Chest pain (-)
 Physical Examination
General appearance Look Moderately ill Sat O2 98% on NC 4 lpm
GCS 456 BMI 19,3 kg/m2
UOP: 2,1 cc/kgbw/h
BP 130/70 mmHg PR 79 bpm regular strong RR 20 tpm T 36,5 oC
Head Conjuctiva Anemic (+), NGT attached 🡪 production was clear
Neck JVP R+2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing :
-|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-|- - |-
Cardio Ictus palpable at MCL (S) ICS VI
S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space dullness
Extremities Edema (-), pale (-)

RT Tonus sphincter ani (+); colon mucous slippery; melena (+)

 Laboratory Findings (01/11/2020)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 21.850 4.700 – 11.300 /µL Ureum 106.3 20-40 mg/dL
Hemoglobine 5,50 11,4 - 15,1 g/dl Creatinine 1.68 <1,2 mg/dL
PCV 16.00 38 - 42% BUN/Cr 29,5
Thrombocyte 203.000 142.000 – Natrium 133 136-145 mmol/L
424.000 /µL
MCV 83.80 80-93 fl Kalium 4.59 3,5-5,0 mmol/L

MCH 28.80 27-31 pg Bilirubin total 0.82 <1.0 mg/dl

Eo/Bas/Neu/ 0.1/0,1/76.9/ 0-4/0-1/51-67/ Bilirubin direct 0.27 <0.25 mg/dl

Limf/Mon 13.2/9.7 25-33/2-5
Bilirubin indirect 0.35 <0.75 mg/dl
SGOT 54 0-40 U/L Glucosa 191 >60
SGPT 46 0-41 U/L PPT 12,6 (10,7)
Albumin 3.88 3,5 – 5,5 mmol/L INR 1,23
HbsAg NR APTT 23,2 (25,4)
AntiHCV Reactive RBS 191
 Blood Gas Analysis (11/01/2020)

With Room Air Normal

pH 7.42 7.35-7.45
pCO2 26.8 35 – 45 mmHg
pO2 105.1 80 – 100 mmHg
HCO3 17,5 21 – 28 m mol/L
O2 saturation 97.0% > 95 %
BE -7.2 (-3) - (+3) m mol/L
Temperature 37
Hb 7,1
Conclusion: Acidosis Metabolic Fully Compensated
Electrocardiography (1/11/2020)
 Electrocardiography (1/11/2020)

• Sinus rhythm, HR 82 bpm

• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : 0,08 s
• PR interval : 0,12 s
• QRS complex : 0,08 s
• ST segment : isoelectric
• QT interval : 0,36 s
• Other : q patologis V1-V3

Conclusion : Sinus Rhytm, HR 82 bpm, OMI anterior

Chest X-Ray (1/11/2020)
 Chest X-Ray (1/11/2020)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Intercostal space was widened
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: infiltrate at apeks D
• Cor: site N, size CTR 55%, shape tear drop appearance,
calcification aorta (+), cardiac waist (+)

Conclusion:
Emphysematous lung, Lung TB
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 1. Upper GI 1.1 Variceal Endoscopy Non-pharmacology: PMo :
Bleeding bleeding - Bed rest GI bleeding,
Subjective: 1.1.1 rupture of - O2 2-4 lpm NC Reaction of
- Black tarry stool (+) since 2 esophageal - Temporary fasting 🡪 GL transfusion,
days, 3x/day, volume 50 cc variceal CBC/24h
1.1.2 portal every 8 hours, if GC
- Coffee ground vomiting (+) clear 3x, start fluid diet
1x/day, volume 200 cc hypertensive PEdu :
- Diagnosed as cirrhosis and gastropathy 6x200cc About UGIB
hepatitis C infection since 8 - IVFD NaCl 0,9% and
years ago 1.2 Non variceal 1500cc/24h management
bleeding
Objective: 1.2.1. Peptic Pharmacology:
BP : 130/70 mmHg ulcer bleeding - Drip Ocreotide 50
HR : 79 bpm, RR: 20tpm 1.2.2. Erosive mcg/hour
SpO2 98% on NC gastritis - IV Ceftriaxone 1x1gr
H/N: anemic conjunctiva (+), - IV Lansoprazole 1x30mg
NGT (+) with GC Clear 1x - IV Metoclopramide
RT: melena (+)
3x10mg
Laboratory: - PRC Transfusion 1
Hb: 5,5 kolf/day, until Hb level
MCV/MCH: 83,8/28,8 7-9 g/dL
AntiHCV: Reactive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 2. Cirrhosis - - Non-pharmacology: PMo :
hepatis child - Bed rest Abdominal
Subjective: pugh class A - O2 2-4 lpm NC USG
- Black tarry stool (+) since 2 days, post necrotic - IVFD NaCl 0,9% evaluation
3x/day, volume 50 cc hepatitis C
infection 1500cc/24h PEdu :
- Coffee ground vomiting (+)
1x/day, volume 200 cc About
- Diagnosed as cirrhosis and Pharmacology: cirrhosis
hepatitis C infection since 8 years - Plan to give antiviral hepatis and
ago - PO Spironolactone 1x100 treatment
mg (postponed)
Objective: - PO Propanolol 3x10 mg
BP : 130/70 mmHg (postponed)
HR : 79 bpm, RR: 20tpm - PO Lactulosa syr 3xCI
SpO2 98% on NC
H/N: anemic conjunctiva (+), NGT
(+) with GC Clear 1x
Abd: traubes space dullness
RT: melena (+)

Laboratory:
Hb: 5,5/ MCV/MCH: 83,8/28,8
INR 1,23/ Albumin 3,88
Bil. T/D/I 0,62/0,27/0,35
AntiHCV: Reactive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 3. Anemia 3.1 acute Reticulocyte Non-pharmacology: PMo :
normochrome blood loss Blood smear - Bed rest bleeding
Subjective: normocyter 3.2 chronic - O2 2-4 lpm NC sign,
- Black tarry stool (+) since 2 inflammation - IVFD NaCl 0,9% reaction of
days, 3x/day, volume 50 cc transfusion,
1500cc/24h CBC/24h
- Coffee ground vomiting (+)
1x/day, volume 200 cc
- Diagnosed as cirrhosis and Pharmacology: PEdu :
hepatitis C infection since 8 - PRC Transfusion 1 About
years ago kolf/day, until Hb level anemia and
7-9 g/dL transfusion
Objective:
BP : 130/70 mmHg
HR : 79 bpm, RR: 20tpm
SpO2 98% on NC
H/N: anemic conjunctiva (+),
NGT (+) with GC Clear 1x
RT: melena (+)

Laboratory:
Hb: 5,5
MCV/MCH: 83,8/28,8
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 4. Type 2 DM - - Pharmacology: PMo :
Normoweight - PO Glimepiride 1x4 mg FBG/2hPPBG
Subjective: every 72h
- Diagnosed as DM since 8 years
ago, routinely consumed PEdu :
glimepiride 1x 4mg About DM
and treatment
Objective:
BMI : 19,3 kg/m²

Laboratory:
RBS: 191 mg/dL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 5. Acute 1.1 volume - - Rehydration 500cc PMo :
Kidney depletion dt No 1 NaCl 0,9% 🡪 IVFD UOP/24h
Subjective: Injury 1.2 hepatorenal NaCl 0,9% 1500cc/24h Ur/Cr every
- Black tarry stool (+) since 2 stage 1 syndrome type 2 - Treat underlying 3 days
days, 3x/day, volume 50 cc
disease PEdu :
- Coffee ground vomiting (+)
1x/day, volume 200 cc About AKI
- Diagnosed as cirrhosis and and
hepatitis C infection since 8 treatment
years ago

Objective:
BP : 130/70 mmHg
HR : 79 bpm
UOP: 2,1 cc/kgbw/h

Laboratory:
Ur/Cr 106,3/1,68
BUN/Cr 29.5
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 6. Chronic hepatitis - - - Plan to give antiviral PMo :
C infection HCV-RNA
Subjective:
- Diagnosed as hepatitis C PEdu :
infection since 8 years ago About
hepatitis C
Objective: and
liver span: 10 cm treatment

Laboratory:
AntiHCV : Reactive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 7. Lung TB 7.1 active Sputum - Confirmed diagnosis 🡪 PMo :
infection Gen Expert OAT as indicated ~ Subjective,
Subjective: 7.2 inactive pulmonology departement VS
History of Lung TB in 2012,
got treatment of TB for 6 PEdu :
months and resolved About lung
TB and
Objective: treatment
RR : 20 tpm, T: 36,5°C
SpO2 : 98% NC
BMI : 19,3 kg/m²
Pulmo : ronchi-/-, wh -/-

CXR:
Lung TB
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. FH/61 yo/ intensive ward 8. Stable - - Therapy from pulmonoly PMo :
COPD department : S, VS
Subjective: - PO Retaphyl SR 2x 1/2
He was a smoker since the age of tab PEdu :
12, around 12 bars/day About
- PO NAC 3x200 mg COPD and
Objective: treatment
RR : 20 tpm
SpO2 : 98% NC
Pulmo : ronchi-/-, wh -/-

CXR:
Emphysematous lung
 Problem Analysis

Hepatitis C infection

CIRRHOSIS HEPATIS

Portal hypertension

Anemia AKI
acute
blood loss Volume
depletion
UGIB
 Risk Factors Analysis
Problem Theory Patient

• Alcoholic liver disease

• Chronic Hepatitis C
infection
• Chronic Hepatitis B
infection
• Steato hepatitis non
alcoholic (NASH)
• Primary Biliary Cirrhosis
• Primary colangitis sclerosis
• Autoimmune hepatitis
• Herediter hemochromatosis
CIRRHOSIS On the Patient :
• Wilson disease
HEPATIS Hepatitis C
• Alpha 1-antitrypsin
deficiency
• Cardiac Cirrhosis
• Galactosemia
• Cystic Fibrosis
• Hepatotoxic because of
drug and toxin
• Schistomiosis

PAPDI
Key Messages Pathophysiology

McMaster
Management Analysis Cirrhosis

Refference : AAFP
 Key Message Social

• Family support is necessary to encourage the

patient for taking medicine routinely.
• Educate the patient and the family that repeating
episode of GI bleeding can be prevented by taking
medicine regularly.
 Condition This Morning

• GCS : 456
• BP : 120/70 mmHg
• HR : 98 bpm
• RR : 20 tpm
• T : 36,8oC
• SpO2 : 98% NC