MORNING REPORT

June 19th, 2019

Coass in charge
Ara Bella Diyanti
Anindita Nurul Fauziah
Dody Prasetya
Dwiky Ilham
Firstya Dyah E
Zaida Hanum

Chief on duty : dr. Ayu

Consultant on duty : dr. Dewi Indiastari Sp.PD
 Summary of Database
Mr. H/63 yo/ward.06
Heteroanamnesis with his family
Chief Complaint: decrease of consciousness
History of Present Illness:
• Patient had decrease of consciousness since 3 days before admission. Initially he felt weak and tend
to be sleepy. In the last 1 day, he was difficult to be woken.
• He had decrease of appetite since 3 days before admission. Previously, he could only eat porridge and
some soft food. In the last 3 days, he barely eat at all.
• Since 2 weeks before admission, sometimes he had cough, with the sputum was difficult to be
expulsed.
• He also had almost constant hiccup since 3 weeks ago. The hiccup stopped 4 days ago.
• In the last 24 days, he was only bedridden. He used urinary catheters and also diapers because of the
incontinence of urine and feces. He also had wound at his buttock and left hip since about 1 week.
The skin was initially reddened and slowly it became wounded.
• He had hypertension for >10 years, with highest BP was 160/-, but he did not routinely take any
medication.
• He had CVA in May 24th, 2019 and was hospitalized for about 14 days. When he had CVA, his left body
was paralyzed with slurred speech.
 Summary of Database
Past Medical History:
• He had surgery of glaucoma in May 5th, 2019.
Family History:
No family history of CVA.
Social History:
He did not work. He lived with his wife.
Review of System:
Fever (-).
 Physical Examination
General appearance looked moderately ill Sat O2 98% on 8 lpm
GCS 356 VAS 0/10
BP 140/80 mmHg PR 115 bpm regular strong RR 20 tpm Tax 37oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Meningeal Sign (-), Pupil Isocor 3 mm/3mm
Visusdifficult to evaluate
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 1 cm lateral MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, epigastrium tenderness (-)
Liver/ unpalpable, liver span 10 cm,
Lien/ Traube space tympani
Extremities Edema (-), pale (-), MMT 5 | 1 , ulcer at left hip covered by bandage, ulcer at buttock covered by bandage
5|1
Genitourinary UOP =600 cc/4 h Urine color dark yellow
Ulkus decubitus
 Laboratory Findings (16/06/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 16.090 4.700 – 11.300 /µL Ureum 162.2 20-40 mg/dL

Hemoglobin 17.9 11,4 - 15,1 g/dl Creatinine 1.64 <1,2 mg/dL

PCV 52.9 38 - 42%

Thrombocyte 83.000 142.000 – 424.000 /µL Natrium 146 136-145 mmol/L

MCV 91.5 80-93 fl Kalium 4.57 3,5-5,0 mmol/L

MCH 31.0 27-31 pg Chlorida 116 98-106 mmol/L

Eo/Bas/Neu/ 0.0/0.1/84.0/2 0-4/0-1/51-67/ RBS 237  185 < 200 mg/dl

Limf/Mon .7/13.2 25-33/2-5
PPT 13.5 9.3-11.4 detik
SGOT 50 0-40 U/L APTT 24.5 24.8-34.4

SGPT 43 0-41 U/L INR 1.33 0.8-1.30

Albumin 3.25 3.5-5.5 g/dL Calcium 7,6-11,0

Lactic acid 2.6 EGFR 29 ml/min/1.73 m2

BUN/Cr 46.2
 Urinalysis (16/6/2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity Slight turbid 10 x
Color Yellow Epithelia - ≤1
pH 6.0 4.5 – 8.0 Cylinder -
SG 1.015 1.005 – 1.030 40 x
Glucose Negative negative Erythrocyte 54.1 ≤3
Protein 1+ negative Eumorphic 71%
Keton Negative negative Dysmorphic 29%
Bilirubin 2+ negative Leukocyte 41.7 ≤5
Urobilinogen 66 negative Crystal -
Nitrite Positive negative Bacteria 771.2x10^3 ≤23 x 103/ml
Leukocyte 2+ negative Other
Erythrocyte 3+ negative
 Blood Gas Analysis (16/06/2019)
With 8 lpm Normal
pH 7.46 7.35-7.45
pCO2 23.2 35 – 45 mmHg
pO2 76.6 80 – 100 mmHg
HCO3 16.5 21 – 28 m mol/L
O2 saturation 96.1% > 95 %
BE -7.6 (-3) - (+3) m mol/L
Temperature
Hb

Conclusion: metabolic acidosis fully compensated

Electrocardiography (16/06/2019)
Chest X-Ray (16/06/2019)
 The Barthel Index

0
0

0
0

0
0
0
 0

1
1

0.5
0

0
2

1 0.5

0
1

0.5

9.5
SOFA score 4
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 1. Septic 1.1 Blood Non pharmacology PMo:
Subjective condition Complicated culture & • Bed rest, proper Subj, VS
• Gradual DOC 3 days, tend to be lower UTI Ab positioning, chest Fluid
sleepy, Decrease of appetite 1.2 Ulcus sensitivity physiotherapy balance,
• Productive cough 2 weeks, sputum decubitus gr 3 • O2 NRBM 8 lpm UOP, lactic
difficult to expulse 1.3 CAP Urine • Equal fluid balance acid
• Using urinary catheter 24 days culture & • Fluid diet 6x200 cc
• Bedridden 24 days  pressure Ab • Wound care PEdu:
ulcers (buttock, hip) 1 week sensitivity • Regular changes of Condition,
Objective urinary catheter every causes,
Looked moderately ill, GCS 356 Wound 2 weeks manageme
BP 140/80 mmHg, HR 115 tpm base nt,
RR 20 tpm, SpO2 98% NRBM culture & Pharmacology monitoring
Cold acral (+), Pressure ulcer (+) at Ab IVFD NaCl 0.9% , risk of
left hip (grade 2) and gluteal (grade 3) sensitivity rehydration 500 cc  worsening
UOP 600 cc/4 h, dark yellow 1500 cc/24 h condition
Laboratory Sputum Treatment of underlying
Leukocyte 16.090; PLT 83.000 culture & infection
Lactic acid 2.6; Cr 1.64 Ab - IV Ceftriaxone 2x1 gr
UL: nitrit (+), leukocyte 41.7/hpf, sensitivity
erythrocyte 54.1/hpf; bacteria
771.2x10^3/ml
BGA metabolic acidosis fully
compensated
CXR pneumonia
SOFA score 4
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 2. Urine Non pharmacology PMo:
Subjective Complicated culture & • Bed rest, proper Subj, VS
• Gradual DOC 3 days, tend to be Lower UTI Ab positioning Fluid
sleepy, Decrease of appetite sensitivity • Equal fluid balance balance,
• Using urinary catheter 24 days • Regular catheter changes UOP,
• Had CVA 24 days ago  urinary every 2 weeks urinalysis 3
incontinence days
Objective Pharmacology
UOP 600 cc/4 h, dark yellow IVFD NaCl 0.9% rehydration PEdu:
Laboratory 500 cc  1500 cc/24 h Disease,
Leukocyte 16.090; Cr 1.64 Treatment of underlying causes, risk
UL: nitrit (+), leukocyte 41.7/hpf, infection of
erythrocyte 54.1/hpf; bacteria - IV Ceftriaxone 2x1 gr prolonged
771.2x10^3/ml catheter
use, regular
catheter
changes
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 3. Ulcus Wound Non pharmacology PMo:
Subjective decubitus base • Bed rest, proper Subj, VS,
• Gradual DOC 3 days, tend to grade 3 culture & positioning, wound
be sleepy, Decrease of appetite Ab • O2 NRBM 8 lpm healing
• Had CVA 24 days ago sensitivity • Equal fluid balance
• Bedridden 24 days  pressure • Wound care PEdu:
ulcers (buttock, hip) 1 week Disease,
Objective Pharmacology causes,
Pressure ulcer (+) at left hip IVFD NaCl 0.9% rehydration wound
(grade 2) and gluteal (grade 3) 500 cc  1500 cc/24 h care,
Laboratory Treatment of underlying prevention
Leukocyte 16.090 infection of further
- IV Ceftriaxone 2x1 gr ulcer
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 4. CAP Sputum Non pharmacology PMo:
Subjective culture & • Bed rest, proper Subj, VS
• Gradual DOC 3 days, tend Ab positioning, chest
to be sleepy, Decrease of sensitivity physiotherapy PEdu:
appetite • O2 NRBM 8 lpm Disease,
• Productive cough 2 • Equal fluid balance causes,
weeks, sputum difficult to proper
expulse Pharmacology chest
• Had CVA 24 days ago IVFD NaCl 0.9% rehydration physiothera
• Bedridden 24 days 500 cc  1500 cc/24 h py, further
Objective Per NGT NAC 3x200 mg prevention
RR 20 tpm, SpO2 98% NRBM Treatment of underlying of
Rhonki(+) basal sinistra infection pneumonia
Laboratory - IV Ceftriaxone 2x1g
Leukocyte 16.090
CXR pneumonia
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 5. AKI stage I 5.1 Septic - Non pharmacology PMo:
Subjective MODS • Equal fluid balance Subj, VS,
• Gradual DOC 3 days, tend to 5.2 Volume • Fluid diet 6x200 cc fluid
be sleepy, Decrease of appetite depletion balance, Ur
• Productive cough 2 weeks, Pharmacology and Cr
sputum difficult to expulse IVFD NaCl 0.9% rehydration every 3
• Using urinary catheter 24 days 500 cc  1500 cc/24 h days
• Bedridden 24 days  pressure Treatment of underlying
ulcers (buttock, hip) 1 week infection PEdu:
Objective Condition,
GCS 356, BP 140/80 mmHg, HR causes,
115 tpm, Cold acral (+) manageme
Pressure ulcer (+) at left hip nt, risk of
(grade 2) and gluteal (grade 3) worsening
UOP 600 cc/4 h, dark yellow condition
Laboratory
Leukocyte 16.090; PLT 83.000
Lactic acid 2.6; Cr 1.64
UL: nitrit (+), leukocyte 41.7/hpf,
erythrocyte 54.1/hpf; bacteria
771.2x10^3/ml
CXR pneumonia
SOFA score 4
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 6. 6.1 Septic - Non pharmacology PMo:
Subjective Thrombocyto DIC • Bed rest, proper Subj, VS,
• Gradual DOC 3 days, tend to be penia + positioning CBC every 3
sleepy, Decrease of appetite prolonged • Equal fluid balance days, FH
• Productive cough 2 weeks, INR • Wound care every 3
sputum difficult to expulse days, signs
• Using urinary catheter 24 days Pharmacology of bleeding
• Bedridden 24 days  pressure IVFD NaCl 0.9% rehydration
ulcers (buttock, hip) 1 week 500 cc  1500 cc/24 h PEdu:
Objective Treatment of underlying Condition,
Looked moderately ill, GCS 356 infection causes,
Cold acral (+) manageme
Pressure ulcer (+) at left hip nt,
(grade 2) and gluteal (grade 3) monitoring,
UOP 600 cc/4 h, dark yellow risk of
Laboratory bleeding
Leukocyte 16.090; PLT 83.000
Lactic acid 2.6; Cr 1.64
UL: nitrit (+), leukocyte 41.7/hpf,
erythrocyte 54.1/hpf; bacteria
771.2x10^3/ml
INR 1.33
CXR pneumonia
SOFA score 4
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 7. CVA sequele Non pharmacology PMo:
Subjective • Bed rest, proper Subj, VS,
• Had CVA 24 days ago positioning, chest signs of
• Bedridden 24 days physiotherapy new
• HT >10 years, highest BP • Regular changes of neurologica
>160, not routinely take urinary catheter every 2 l deficit
medication weeks
• Prolonged hiccup • Equal fluid balance PEdu:
Objective • Fluid diet 6x200 cc Condition,
Looked moderately ill, GCS causes, risk
356 Pharmacology of
BP 140/80 mmHg Per NGT Clopidogrel 1x75 complicatio
Motoric: left hemiplegia mg n of
Laboratory Per NGT Atorvastatin 0-0- prolonged
- 40 mg bedridden
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 8. Mild 8.1 Low intake Non pharmacology PMo:
Subjective hypoalbumine 8.2 Renal loss • Fluid diet 6x200 cc, extra Subj, VS,
• Using urinary catheter 24 mia 8.3 Wound albumin albumin
days loss • Wound care every 3
• Bedridden 24 days  days
pressure ulcers (buttock, Pharmacology Urinalysis 3
hip) 1 week - days
• Decrease of appetite
Objective PEdu:
Pressure ulcer (+) at left hip Condition,
(grade 2) and gluteal (grade causes,
3) manageme
UOP 600 cc/4 h, dark yellow nt
Laboratory
Cr 1.64
UL: proteinuria 1+
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 9. HT stage II Non pharmacology PMo:
Subjective • O2 NRBM 8 lpm Subj, VS,
• Had CVA 24 days ago • Equal fluid balance TOD
• HT >10 years, highest BP • Fluid diet 6x200 cc
>160, not routinely take PEdu:
medication Pharmacology Disease,
Objective Lisinopril 1x5mg complicatio
Looked moderately ill, GCS n, therapy
356 compliance
BP 140/80 mmHg , risk of
Cardiomegaly (+) worsening
Motoric: left paraplegia condition
Laboratory with
Proteinuria1+ further
ECG sinus tachycardia, HR complicatio
120 bpm n
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 10. HF stage B 9.1 HHD Non pharmacology PMo:
Subjective • O2 NRBM 8 lpm Subj, VS,
• Had CVA 24 days ago • Equal fluid balance functional
• HT >10 years, highest BP • Fluid diet 6x200 cc class, fluid
>160, not routinely take balance
medication Pharmacology
Objective Lisinopril 1x5mg PEdu:
Looked moderately ill, GCS Condition,
356 causes,
BP 140/80 mmHg manageme
Cardiomegaly (+) nt, risk of
Motoric: left paraplegia worsening
Laboratory condition,
- therapy
ECG sinus tachycardia, HR compliance
120 bpm
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 11. Glaucoma Non pharmacology PMo:
Subjective post surgery Consult to opththalmology Subj, VS
• History of glaucoma department
surgery in May 5th, 2019 Eye hygiene PEdu:
Objective Disease,
Visus difficult to evaluate Pharmacology possibility
Laboratory - of causes,
- consultatio
n to
opththalmo
logy
department
for post
surgery
care
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. HS/63 yo/ w.06 12. Geriatric - - Non pharmacology PMo:
Subjective problem • Bed rest, proper Subj, VS
• Gradual DOC 3 days, tend to be (infection, positioning, chest
sleepy, Decrease of appetite inanition, physiotherapy PEdu:
• Productive cough 2 weeks, immobilizatio • Equal fluid balance Condition,
sputum difficult to expulse n, impairment • Fluid diet 6x200 cc causes,
• Using urinary catheter 24 days of vision, • Wound care comprehen
• Bedridden 24 days  pressure incontinence) • Regular changes of sive
ulcers (buttock, hip) 1 week urinary catheter every 2 manageme
• History of glaucoma surgery in weeks nt,
May 5th, 2019 • Family support importance
Objective of family
Visus difficult to evaluate; Left Pharmacology support,
hemiplegia Consult to Physiotherapy prevention
Pressure ulcer (+) at left hip (grade considering passive of further
2) and gluteal (grade 3) exercise complicatio
UOP 600 cc/4 h, dark yellow n
Laboratory
Leukocyte 16.090
UL: nitrit (+), leukocyte 41.7/hpf,
erythrocyte 54.1/hpf; bacteria
771.2x10^3/ml
CXR pneumonia
SOFA score 4
Barthel Index: 0; MNA 9.5
 Condition This Morning

• GCS : 356
• BP : 130/90 mmHg
• HR : 131 bpm
• RR : 35 tpm
• Tax : 35,0oC
• SpO2 : 99% on NRBM 10 lpm