Morning Report

Friday, December 22nd 2014

Physicians in charge:
Jaga
Jaga
Jaga
Jaga

IA
IB
II
III

:
:
:
:

dr. Sasmithae, dr. Somarnam, dr. Kathy

dr. Vina, dr. Dikara, dr. Etik
dr. Ananto
dr. Sri Sunarti, Sp.PD-KGER

Moderator MR: dr. Supriono, Sp.PD-KGEH

Summary of Data Best

Sumiati/71Yo/w22
Anamnesis: autoanamnesa and heteroanamnesis (patients
daughter)
Chief complained: Shortness of breath
Patient suffered from shortness of breath since 1 weeks before
admission, intermittenlly, and she complained about cough,
without sputum together with shortness of breath.
Sometimes she felt fever, intermittenlly, no chill, and decreased
when she consumed paracetamol.
Patient felt abdominal pain, intermittenly, cramp like sensation,
no vomiting or nausea, diarrhea (-), darktarry stool or darktarry
vomiting (-). Patient complained about decreased of appetite and
she just ate 5-6 spoon per day.

 Now she just laying on bed because she fel

weakness and for did activity she needed help
from her daughter.
She didnt have hypertension or diabetes
mellitus
History of pass illness:
history of darktarry stool 5 years ago
Familly history : (-)
Social history:
married once, have 2 children, house wife, no
history consumed traditional potion or pain
killer before

PHYSICAL EXAMINATION
General Appearance: moderately ill

Looked normoweight

BP: 110/70 mmHg

Head

Pupil isokor, diameter: 3 mm,pale conjungtiva (+)

Neck

JVP R+ 2 cm, lymphnode enlargement -/-

Chest

RR: 24 tpm with

O2 4 lpm NC

PR: 82 bpm regular strong

GCS: 4.5.6

Wall

Normal

Heart

Ictus invisible, palpable at ICS V cm lateral MCL S

RHM ~ SL D
LHM ~ ictus
HR: 80 beats per minute, S1 and S2 single, murmur -

Lung

Stem Fremitus D=S S S v v Rh

S S bv v
D S bv v

-++-

Trill: -

Tax: 36,7C

Heaves: -

Wh - - - -

Abdomen

flat, bowel sound normal, supple, liver span 8 cm , Traubes space tympanic, sikatric post of gall
bladder (+)

Extremities

Warm; edema +/+ , lateralisation (-)

+/+
sensory : normal/normal
motoric 5/5
4/4

Laboratory finding
Lab

Value

Lab

Value

Leukocyte

2.790

3.500-10.000/L

Natrium

120

136-145 mmol / L
280-295 mOsm/kg

Haemoglobine
MCV

9.20
84.70

11,0-16,5 g/dl
80-97

Kalium

3.30

3,5-5,0 mmol / L

MCH

28.20

26,5-33,5

Chlorida

96

98-106 mmol / L

PCV

27.60%

35-50%

RBS

125

< 200 mg/dL

Trombocyte

156.000

146.000390.000/L

Ureum

21.20

10-50 mg/dL

0.4/0.1/51-67/
25-33/2-5

Creatinine
Blood
smear

Eo/Ba/Neu/Ly/
Mo

0.0/0.1/13.6/
63.1/22.2

SGOT

37

0-32 U/L

SGPT

82

0-32 U/L

0.55

0,7-1,5 mg/dL

Eritrocyte: normochrom
anisocytosis, makroovalosit (+)
Leucocyte: decreased, netrofilia
Trombocyte: normal

URINALYSIS 20 JANUARY 2014

10x

Clarity

Clear

Epithel

Color

Yellow

Cylinder

6.0

4,5-8,0

pH
Specific gravity

1.020

positif

0-1

Negative

Erytrocyte

0-1

Eumorphic

Dismorphic

Leucocyte

2-6

Cristal

Bacteria

93 x 103/mL

Hyalin

1,005-1,030 Granular

Glucose

Negative

Protein

1+

Negative

Keton

Negative

Bilirubin

Negative

Urobilinogen

Negative

Nitrit

Negative

Leucocyte

Negative

Erytrocyte

Tracedlyced

Negative

Other

BGA
Laboratory Finding

With 02 supplementation 4 lpm NC

PH

7.33

7,35-7,45

PCO2

38.1

35-45

PO2

62.8

80-100 mmHg

Truly O2

mmHg

80 100

HCO3

20.1

21-28

mmHg

O2 saturation

90.0%

> 95 %

Base Excess

-6.0

-3 until +3

Hb

15.2

g/dL
0.5 2.2 mmol/L
0.5 1.1 mmol/L

Suhu

37.0

Conclusion

Ascidosis
metabolic
partially
compensated

Port score
Women +61
Temp >350 C +15
pH < 7.35 +30
Na <130 mEq/L +20
Hematocrite 27.60% +10
Pleural effusion +10
Total score: 146

Chest X-Ray

CHEST X RAY INTERPRETATION

AP position, asymmetry, enough KV, enough inspiration

Trachea in the middle
Mediastinum normal
Soft tissue and bone normal
Hemidiaphragma Right and left were dome shape
Costophrenical angle Right: covered by radioopaque
shadow and left : sharp
Infiltrate in lower lobe lung dextra (+), lung sinistra was
normal
CTR: 58%, cardiac waist (+)
Conclusion: pneumonia with minimal pleural effusion (D)

ECG

ECG interpretation
Sinus tachycardia with heart rate 136 beat per minute
Frontal axis: normal
Horizontal axis: left axis deviation
PR interval: 0.20 second
QRS kompleks: 0.08 second
QT interval: 0.28 second
Low voltage in lead I-III,aVL, aVR and aVF
QS pattern in lead V1-V4
LV strain in lead V1-V4
Conclussion: sinus tachycardia with HR 136 bpm with OMI
anteroseptal and ischemic anterior septal wall

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Female/71 Yo
Cough,
fever,without
sputum
Decreased of
appetite
Laying on bed
because
weakness
PE:
RR: 26 tpm with
O2 4 lpm Nasal
canul
Tax:36.70 C
Lab:
Hb: 9.20
Wbc: 2790
Neutrofil: 13.6%
Neutrofil
count:379.44
Lymfosit: 63.1%
TLC:1760.49
Monocyte: 22.2%
CXR: pneumonia
with minimal

Problem List
1. Pneumonia
with port score
146

Initial
Diagnosis

Planning
Planning
Planning Monitoring and
Diagnosis
Therapy
Education
Blood culture
Bed rest
Monitoring:
and sensitivity
Subjective
O2 4-6 lpm Nasal Vital signs
Sputum culture canul
BGA
and sensitivity
CBC
IVFD NS 0.9% 20
tpm
Education:
Using masker
Inf. Levofloxacin
1 x 750 mg
Reference:
(intravenous)
Pedoman diagnosis dan
penatalaksanaan
PO: NAC 3 x 200 pneumonia komunitas di
mg (for produce Indonesia
mucolitic for

sample culture)

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Female/71 Yo
Weakness
Fever
Decreased of
appetite
Laying on bed
PE:
Pale conjungtiva
(+)
Lab:
Hb: 9.20
MCV: 84.70
MCH: 28.20
Wbc: 2790
Neutrofil: 13.6%
Neutrofil
count:379.44
Lymfosit: 63.1%
TLC:1760.49
Monocyte: 22.2%
Blood smear:

Eritrocyte:
normochrom
anisocytosis,
makroovalosit (+)
Leucocyte:

Initial
Planning
Diagnosis
Diagnosis
Bone marrow
2. Bicytopenia 2.1
(anemia+leuco myelodisplasia pucture
penia)
syndrome
Problem List

2.2 anemia
aplastic

Planning
Therapy
Confirm
diagnosed

Planning Monitoring and

Education
Monitoring:
Subjective
Vital signs
CBC
Bleeding tendency
Education:
Prognosis from the
disease, plan theraphy
and prognosis

Reference:
Pedoman diagnosis dan
terapi
Hematologi onkologi
medik 2003

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Female/71 Yo
Weakness
Decreased of
appetite
Just ate 5-6 spoon
per day
Laying on bed
PE:
Edema in
ekstremities
sup.and inf. D/S
Lab:
Alb: 2.27 g/dl
CXR:
Pneumonia with
minimal pleural
effusion (D)

Initial
Diagnosis
3.1
3.
hypoalbuinemi hypercatabolic
a
state
Problem List

3.2 low intake

Planning
Diagnosis

Planning
Therapy
Soft diet HCHP
1900 kcal per
day with extra
white egg and
extra brooth

Planning Monitoring and

Education
Monitoring:
Subjective
Vital signs
Albumin
Edema
UOP
Education:
Consumed food contains
fish, meat, eeg

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Female/71 Yo
Abdominal pain
Decreased of
appetite
Cramp like
sensation
History of darktarry
stool
Colonoscopy:
Gastritis erosiva
with ulcus in
antrum

Problem List
4. Gastritis
erosiva

Initial
Diagnosis

Planning
Diagnosis

Planning
Therapy
Soft diet HCHP
1900 kcal per
day with extra
white egg and
extra brooth

Planning Monitoring and

Education
Monitoring:
Subjective
Vital signs

Inj. Omeprazole
1 x 40 mg

PO: sucralfat 3 x
30 cc

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Female/71 Yo
Decreased of
appetite
Need help to do all
activity
Weakness
Motoric: 5/5
4/4
Edema
ekstremities sup
and inf dextra
sinistra
Barthel index 15
MNSA : 9.5
(malnutrition)

Problem List
5. Geriatric
problem

Initial
Diagnosis
5.1
immobilitation

Planning
Diagnosis

Planning
Therapy
Consult to
geriatric
department

Planning Monitoring and

Education
Monitoring:
Subjective
Vital signs

5.2 Instability
Fisiotheraphy
5.3 inanition
5.3 infection

Problem analysis
geriatric
pneumonia

immunocomp
romissed

Shortness of
breath

MDS

Anemia
aplastic

History of
melena

hypoalbuminem
ia
Hypercatabolic
state

Lymfopenia+an
emia

Low intake

Gastritis erosiva

Risk Factor Analysis

1.Genetics factor
2.Chemicals
3. Viral infection
4. Environmental ( high dose of
radiation,
exposure to toxic chemicals)
5. Immune system deficiencies

Management analysis
Urgency:
O2 nasal canul 4-6 lpm
IVFD NS 0.9% 20 tpm
inf. Levofloxacin 1 x 750 mg (intravenous)
Non urgency:
Inj. Omeprazole 1 x 40 mg (intravena)
PO: NAC 3 x 200 mg (for produce mucolitic for sample culture)
Sucralfat 3 x 30 cc
Soft diet HCHP 1900 kcal per day with extra white egg and extra
brooth

 Thank You

5
0
0
0
5
0
5

15

Mini Nutritional Assessment

1
1
2
1
2

+
+
+

1
1
1

0.5
0
1
1

0.0
0
9.5

Value: 9.5
If < 17
Malnourished

Subjective Global Assessment

+
+
+

1 week
1 week
2 days

Mild Malnutrition