MORNING REPORT

Friday, 18th May 2018

PHYSICIAN IN CHARGE :
IA : dr. Ade, dr. Arde, dr Reizal, dr. Galih
II CVCU : dr. Eden
II HCU : dr. Ernes
II UGD : dr. Rima , dr. Tio
Chief : dr. Regy
Consultant : dr. Heri Sutanto ,Sp.PD
Facilitator : dr. Niniek Budiarti,Sp.PD-KPTI
 Summary of Database
Mrs. Aidah/ 48 yo/ward 28 Bed 8
Autoanamnesa/Heteroanamnesa
Chief Complaint: General weakness
History of Present Illness:
Patient hospitalized due to general weakness after routine hemodialyzed. She
denied any nausea and vomiting. She also denied hypertension or diabetes mellitus. She said
that her blood pressure usually was 120/70mmHG. She also said that se never check her
blood sugar level. She never consumed antihypertensive drugs. She often consumed
antibiotics such as amoxicillin, cefadroxil and ciprofloxacin. She was CKD patient and routinely
HD every Thursday. History of hyperglycemia.
 Summary of Database
Past Medical History:
Patient never hospitalized due to the same condition.
Family History:
There was no family with hypertension or diabetes mellitus
Social History:
She was a housewives.
Review of System:
Defecation within normal limit
 Physical Examination
General appearance look moderately ill Sat O2 98% room air
GCS 456 VAS 0/10
BP 130/90mmHg PR 78bpm regular strong RR 20 tpm Tax 36.6oC
Head Conjuctiva Anemic (+),
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 invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
Hemic murmur (+) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany
Extremities Edema (-), pale (+), MMT 5 | 5 , Pathologic Reflex (-); Lateralisation(-)
5|5
 Laboratory Findings (waiting for result)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 4.700 – 11.300 /µL Ureum 20-40 mg/dL

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

PCV 38 - 42%

Thrombocyte 142.000 – 424.000 /µL Natrium 136 136-145 mmol/L

MCV 80-93 fl Kalium 2,68 3,5-5,0 mmol/L

MCH 27-31 pg Chlorida 102 98-106 mmol/L

Eo/Bas/Neu/ 0-4/0-1/51-67/ RBS 112 < 200 mg/dl

Limf/Mon 25-33/2-5
PPT 9.3-11.4 detik
SGOT 0-40 U/L APTT 24.8-34.4

SGPT 0-41 U/L INR 0.8-1.30

Albumin 3.5-5.5 g/dL Calcium 7,6-11,0

Bilirubin total <1.0 mg/dl

Bilirubin direct <0.25 mg/dl Osm 275-295 mOsm/kg

Bilirubin indirect <0.75 mg/dl

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. A/48 yo 1. CKD st 5 on - - Non-Pharmacology PMO
routine HD -Bed rest S, VS, UOP
Subjective -IV plug
General weakness -Renal diet 1700kcal/day - P-EDU
Routinely HD Low salt <2gr/day, protein Educate to
Often consumed antibiotics 50gr/day take
-equal fluid balance medicine
Objective routinelly
Conjunctiva anemic (+) Pharmacology
Ext: pale HD as scheduled

Laboratory
-
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w 2. Anemia 2.1 Def EPO - Non-Pharmacology PMO
renal 2.2 Decreased -bed rest S, VS,
Subjective RBC life span transfusion
General weakness Pharmacology reaction
Routinely HD PRC transfusion 2lb/day
until HB>8gr/dl
Objective P-EDU
Conjunctiva anemic (+) Educate to
Hemic murmur (+) take high
Ext: pale (+) iron food

Laboratory
-
 Problem analysis

Anemia Renal CKD

Hemodialyzed

Hypokalemia
 Risk factor Analysis

Problem Theory
CKD Diabetes hyperglycemia
High blood pressure
Heart disease
Smoking
Obesity
High cholesterol
African-American, Native-American or
Asian-American race
Family history of kidney disease
Age 65 or older
Obstruction
 Condition This Morning
• GCS: 456
• BP: 130/80 mmHg
• HR: 92bpm
• RR: 19 tpm
• Tax: 36,30 Celcius
• SpO2 : 98% on RA
Prognosis
• Ad vitam : dubia ad bonam
• Ad sanationam : ad malam
• Ad functionam : dubia ad bonam
THANK YOU