MORNING REPORT

Wednesday, 5th April 2017

PHYSICIAN IN CHARGE:
I : dr. Tata, dr. Bunga, dr. Nadin
II (HCU) : dr. Nudi
II (CVCU) : dr. Akta
II (ER) : dr. Jaja, dr. Reza
Chief on duty : dr. Somarnam
Consultant on duty : dr. Rulli Rosandi, SpPD
MR Facilitator : dr. Bogi Pratomo, SpPD-KGEH
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and War
Cue and Clue Planning d
Initial Diagnosis
Identity: Mrs. F, 29 years old (medical
Emergency: Planning Diagnosis: ER
consultation from pulmonology
department) Urgency: Fibrinogen, D-Dimer, Blood
PRIMARY SURVEY
1. Septic condition culture + sensitivity test
Circulation: warm, Airway: patent,
Planning Therapy:
Breathing: spontaneous due to
SECONDARY SURVEY Bedrest, semifowler position
Anamnesis: Pneumonia CAP O2 10 lpm via NRBM
Chief complaint : Shortness of breath 2. Non Urgency: Liquid diet 6x200cc via NGT
since 2 weeks ago that was getting
worse in the last 1 day. Accompanied 2. Antibiotic Levofloxacine
with productive cough. And fever.
History of CVA 3 years ago since then
Thrombocytopenia 1x750mg as Pulmonology
his activity was restricted on + prolonged PPT preference.
wheelchair. History of Tuberculosis
due to DIC Inj. Vit K 3x10 mg iv
treament since Februari 2017.
Albumine transfusion as
Physical Examination: 3. Lung TB on
General appearance: moderately ill Pulmonology preference
GCS: 4.5.6 BP: 120/60 mmHg. PR: intensive phase of
100x/minute. RR: 30x/minute. Tax:
37.1C. VAS 0/10 1st category of OAT Patient will be in a colaborative
O2 saturation: 96%
Shifting dullness 4. Increase of care with Haematologic division.
Laboratory Result:
transaminase + Planning Monitoring:
Hb: 11,7 g/dl. Leucocyte: 19,840/mcl,
Thrombocyte: 63,000/mcl, Hematocrite hyperbilirubinemia subjective
37%, MCV 85,3 fl, MCH 27 pg; Diff count
3,2/0,5/36,6/45,6/14,1 mainly direct Planning Education: prognosis
RBS 86 mg/dL Ref : PAPDI 2014; Harrison, Textbook
Ureum 23,1 mg/dl; Creatinine 0,3 mg/dL 4.1 OAT-induced of Internal Medicine, 19th Edition.
OT/PT 66/167 U/L; Albumin 1,74 g/dL
PPT 21,7; INR 2,09; APTT 36,6
4.2 Sepsis MODS
Bilirubine T/D/I 6,01/5,74/0,27mg/dl 5. Hypoalbuminemia
Procalcitonin 0,47 ng/m/l
Radiology: 5.1 Hypercatabolic
Chest X ray : Lung TB moderate lesion
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and War
Cue and Clue Planning d
Initial Diagnosis
Identity: Mr. D, 70 years old (medical
Emergency: Planning Diagnosis: Blood-pus ER
consultation from neurology
department) 1. Septic culture + sensitivity test, GDI/II,
PRIMARY SURVEY
enchepalopathy HbA1c, Abdominal USG
Circulation: warm, Airway: patent,
Planning Therapy:
Breathing: spontaneous Urgency:
SECONDARY SURVEY Passive mobilisation/2 hours,
Anamnesis: 2. Septic condition Antidecubitus matress
Chief complaint : Gradually decrease of due to decubitus O2 10 lpm via NRBM
consciousness since 2 days.
Accompanied with slurred of speech ulcer grade I/II a/r Liquid diet 6x200cc via NGT
and seizure 1x. History of vertebral
fracture due to trauma since 3 months
gluteal Inf. Wida KN2 10meq/jam
ago, since then his activity was 3. Hyperglycemia in (500cc in 4 hours)
restricted on bed. Wound on buttock
critically ill Drip insulin start 5IU/h (target
and leg. History of hypertension,
RBG 140-180mg/dl)
routinely used Norvask 1x5mg. Non Urgency:
Physical Examination: postponed until K>3mmol/L
General appearance: severely ill 4. Hypokalemia Inf. Metronidazole 3x500mg
GCS: 1.1.2 BP: 99/62 mmHg. PR:
96x/minute. RR: 30x/minute. Tax: 4.1 Low intake inj. Cefoperazone 2x1gr
36.7C.
R/gluteal : decubitus ulcer grade I/II
5. Hypoalbuminemia Albumine 20% transfusion
Lateralitation - 5.1 Hypercatabolic 100cc/day until albumine
Laboratory Result:
Hb: 11,4 g/dl. Leucocyte: 32,850/mcl, state 5.2 Low intake >2.5g/dl
Thrombocyte: 257,000/mcl, Hematocrite
6. Azotemia renal Wound care
31,9%, MCV 77,4 fl, MCH 27,7 pg; Diff
count 0/0.4/90,6/2,9/6,1 Patient will be taken care by
6.1 HT
RBS 680 mg/dL ; Osmolarity 319 Geriatric Division
Natrium: 127 mmol/l, Kalium: 2,74
mmol/l. Chloride: 92 mmol/l; corrected
nephrosclerosis Planning Monitoring:
Na 141 mmol/L 7. Geriatric problem subjective
SGOT 18mg/dl; SGPT 12mg/dl;
Albumine 2,21g/dl (infection,immobilis Planning Education: prognosis
Ur 110,2 mg/dl; Cr 3,03 mg/dL; eGFR Ref : PAPDI 2014; Harrison, Textbook
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and War
Cue and Clue Planning d
Initial Diagnosis
Identity: Mrs. M 51 years old Emergency: Planning Diagnosis: ER
Medical consultation from OBG Dept
PRIMARY SURVEY Urgency: CT scan abdomen ( as scheduled
Circulation: warm, Airway: patent,
1. Ca Cervix st IV ), blood culture, Urinalysis,
Breathing: spontaneous HbsAg anti HCV (HD preparation)
SECONDARY SURVEY 2. CKD st V newly dx
Anamnesis: Planning Therapy:
Chief complaint : General weakness
3. Septic condition Bedrest, semifowler position
since 1 week. Accompanied with dt Ca Cervix O2 10 lpm via NRBM
nausea and vomiting, sometimes
with shortness of breath. Had 3 years Infusion Rehidration 1000 cc
of chemotherapy and 25x Non Urgency: continued 30 dpm
radiotherapy. Diagnosed as Ca Cervix
4. Hipoalbuminemia Liquid diet 6x200cc via NGT
since 3 years
Physical Examination: 4.1 hypercatabolic Antibiotic Ciprofloxacine 2x200
General appearance: moderately mg as OBG .
state
ill FFP transfusion 4 pack/day
GCS: 4.5.6 BP: 110/60 mmHg. PR: 4.2 septic condition Albumine transfusion 20 % 100
97x/minute. RR: 24x/minute. Tax:
37.1C. 5. Anemia + cc
O2 saturation: 96% thrombocytopenia Plan HD elective today
Laboratory Result:
Hb: 5 g/dl. Leucocyte: 39,380/mcl, 5.1 chemoterapy 2 pack PRC transfusion durante
Thrombocyte: 41,000/mcl, induced HD
Hematocrite 15%, MCV 81.1 fl,
MCH 27 pg; Diff count 5.2 radiotherapy
0/0,1/98.3/0.7/0.9 Patient will be in a colaborative
induced
RBS 96 mg/dL , SE : 119/3.5/97 care with Nephrology division.
Ureum 133.7 mg/dl; Creatinine 6. Hyponatremia Planning Monitoring: urin
5.78 mg/dL
hypoosmolar production, uremic symptomps,
OT/PT 20/7 U/L; Albumin 1,85 g/dL,
eGFR 10 ml/1,73 m2 hypovolemeia SE
PPT16.3(10.6); INR 1.57; APTT Planning Education: prognosis
THANK YOU