MORNING REPORT

Date : Wednesday, February 04th 2020

Physician in charge
I : dr. Dimas, dr. Farah, dr. Jodi, dr. Sandi,
dr. Dheni
II Konsulan Intensif : dr. Reta
II Konsulan Non Intensif : dr. Ferdi
II HCU : dr. Gunawan
II UGD : dr. Hana, dr. Fredo, dr. Reizal
Chief on duty : dr. Efriko
Consultant on duty : dr. Siti Fatma, SpPD
Facilitator : Prof Dr dr. Handono Kalim , SpPD-KR
 Summary of Database
Mrs. SM/ 41 y.o / W.22B 9c
Autoanamnesis
Chief Complaint: Gum Bleeding

History of Present Illness:

• Patient suffered from gum bleeding since ten days before admission. She complained about gum
bleeding with volume 5 mL, and bleeding stopped after 2 minutes. She also complained about
nose bleeding since four days before admission. There were red dark spots on his elbow that
occurred since 2 weeks ago, painless and without itchy sensation. Menstrual period was normal,
without excessive bleeding, duration was about 5-6 day. She was referred from previous hospital
because of low platelets level. She got 9 packs of thrombocyte transfusion from previous
hospital. She had medication with methylprednisolone 16 mg, twice a day
• She was diagnosed with Chronic Kidney Disease since 9 months ago, and routinely HD twice in a
week (Monday & Thursday) at RKZ.
• She was also diagnosed having diabetes mellitus since 4 years ago, she used insulin for her
therapy but she stopped using insulin by herself.
 Summary of Database
Past Medical History:
No remarkable medical history

Family History:
Her mother died because of cervix cancer
Her father had hypertension history
She lived with her husband, without a kid

Social History:
There was no one in his family had disease like this.

Review of System:
Gum bleeding (+)
Purpura and ecchymosis (+)
 Physical Examination
General appearance looked moderately ill Sat O2 97%, with nasal canule
GCS 456 VAS 4/10
BP 120/70 mmHg PR 88 bpm regular strong RR 24 tpm Tax 36,7oC
Head Conjuctiva Anemic (-) BW : 89 kg H : 165 cm BMI 32,7
Neck JVP R+0 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-

Sonor | Sonor Vesicular | Vesicular -|- - |-

Cardio Ictus invisible, palpable at 4 cm MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space tympany, shifting dullness (+)
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-), ptechiae and purpura (+) at
lower extremity
5|5
 Laboratory Findings (04/02/2020)
LAB VALUE NORMAL

Leucocyte 23,060 4.700 – 11.300 /µL

Hemoglobine 9,30 11,4 - 15,1 g/dl

PCV 27,50% 38 - 42%

Thrombocyte 93.000 142.000 – 424.000 /µL

MCV 74,4 80-93 fl

MCH 25,1 27-31 pg

Eo/Bas/Neu/Limf/Mon 0,0/0,1/0,0/96,0/2,3/1,6 0-4/0-1/51-67/25-33/2-5

Kalsium 9,1 7,6 – 11,0 mmol/L

Phospor 2,3 2,7 – 4,5 mmol/L

Natrium 124 136-145 mmol/L

Kalium 4,07 3,5-5,0 mmol/L

Chlorida 96 98-106 mmol/L

Random Blood Sugar 467 mg/dL < 200 mg/dl

Laboratory Findings (04/02/2020)
LAB VALUE NORMAL
Ureum 93,2 16,6 – 48,5
Kreatinin 2,69 <1.2
eGFR 20,98 ml/minute/m3
SGOT 9 0-40 U/L
SGPT 11 0-41 U/L
Electrocardiography (04/02/2020)
 Electrocardiography (04/02/2020)
• Sinus rhythm, HR 92 bpm regular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0.12”
• QRS complex : 0.08”
• Q wave : no pathological Q
• QT interval : 0.38”
• QT interval corrected : 0.41”
• ST segment : isoelectric
• Others :

Conclusion : Sinus Rhythm HR 97 bpm

Chest X-Ray (04/02/2020)
 Chest X-Ray (04/02/2020)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thick and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S can’t be evaluated
• Phrenico-costalis angle D and S was blunt
• Pulmo: bronchovesicular pattern was normal
• Cor: Look bigger than normal

Conclusion:
1. Bilateral pleural effusion with right side dominan
2. Cardiomegaly with Pulmonum Congestive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SM/ 42 y.o / 22B 9C 1. CKD st 5 on 1.1 - Non Pharmacology: S, VS, UOP
Subjective Routine HD Hypertension - Diet renal 1800
• Diagnosed with CKD Nephroslerosis kkal/day, low sodium Education:
since 9 months ago 1.2 Diabetic <2gr/day, protein 0.8- Educate the
• Routinely hemodialysis Kidney Disease 10.0 gr/kgBW/day patiett
once a week - HD as scheduled about
• History of HT since 5 importance
years ago, routinely Pharmacology : of
consumed Amlodipine - Folic Acid 1x5mg performing
1x10 mg - CaCo3 3x500 HD and
• History of uncontrolled drug
DM since 4 years ago compliance

Objective
• Conjungtiva Anemia (+)
• Dry skin, looked pale

Laboratory
Ur/Cr: 93.2/2.69
eGFR: 20.98
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SM/ 42 y.o / 22B 9C 2. 2.1 ITP Bone
Subjective Trombositopen 2.2 HIT Marrow
• Gum bleeding (+) ia + Anemia + 2.3 Puncture
• Nose bleeding (+) Leucocytosis Hematological
• Ptechia (+) Malignancy Reticulocyt
• Purpura (+) e Count

Objective IPF
Purpura and petekie in all
body surface
Liver span 12 cm
Traube space tymphani

Laboratory
Hb 9,30
MCV/MCH 74,30/25,10
WBC 23.060
Diff Count
0,0/0,1/0,0/96,0/2,3/1,6
Plt 93.000

Blood Smear
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. SM/ 42 y.o / 22B 9C 3. DM Type 2
Subjective Poorly
DM since 4 years ago , Overweight
poorly controlled

Objective
BB :
BMI :

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. N/ 18 y.o / W.22 4. HT stages II
Subjective
HT since 5 years ago, good
compliance.

Objective
TD

Laboratory
 Problem Analysis

DM type 2

Trombositopenia CKD St 5 Anemia

Ptechiae and
Purpura Hypertension
 Risk Factors Analysis

Problem Theory Patient

Chronic Kidney Disease Unknown

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 Key Massage

Problem Theory Patient

Thrombocytopenia Unknown

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Key Message Management
Key Message Social
 Condition This Morning

• B/P: 136/80 mmHg

• P/R: 85 bpm
• R/R: 20 tpm
• SpO2: 99% Room Air