MORNING REPORT

Date : 25-07-2019

Physician in charge

I :

II CVCU : dr.

II HCU : dr.

II UGD : dr.

Chief on duty : dr.

Consultant on duty : dr.

Facilitator : dr.
 Summary of Database
Mrs. PR/ 39 y.o/ward 28
Autoanamnesa
Chief Complaint: Diarrhea
History of Present Illness:
• Patients come with diarrhea more than 10 times 1 day ago, blood, red mucus (+), 300 cc.
vomiting more than 10 times approximately 350 cc each vomiting, Fever(+), pain in the
entire abdominal field
• stomach enlarged since 1 day ago..
• Diagnosed kidney failure 1 month ago. Routinely HD every Monday the third shift.
• Diagnosed with SLE since 2 years ago, before the patient routinely took medicine, then
the patient stopped taking medicine 8 months ago because he thought he had recovered.
At first the patient complains of hair loss and often canker sores, redness on the face
especially on the cheeks when exposed to sunlight.
• High blood history for the past 9 months. But it does not routinely control and take
medication. Drugs routinely taken: PO Methylprednisolone 3x8 mg and PO Captopril 3x25
mg mg, Amlodipin 1x10 mg, calos 3x1
 Summary of Database
Past Medical History:

Family History:

Social History:

Review of System:
 Physical Examination
General appearance looked moderately ill Sat O2 99% on RA
GCS 456 VAS /10

BP 120/80 mmHg PR 120 bpm RR 22 tpm Tax 36,8 oC

Head Hiperpigmentation multiple (+), Conjuctiva Anemic (-), Sclera Icteric ( ), Nystagmus
(-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+ 0cmH20, Hiperpigmentation multiple (+)
Chest Hiperpigmentation multiple (+), 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,
murmur (-) gallop (-)
Abdomen Hiperpigmentation multiple (+), tenderness (+), defans muscular (+), metallic
 Laboratory Findings (24/07/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 13.490 4.700 – 11.300 /µL Ureum 130,80 20-40 mg/dL

Hemoglobine 14 11,4 - 15,1 g/dl Creatinine 5,62 <1,2 mg/dL

PCV 38 - 42% Osm 275-295 mOsm/kg

Thrombocyte 216.000 142.000 – 424.000 /µL Natrium 134 136-145 mmol/L

MCV 85,70 80-93 fl Kalium 3,32 3,5-5,0 mmol/L

MCH 30,20 27-31 pg Chlorida 107 98-106 mmol/L

Eo/Bas/Neu/ 0,0/0,1/88/ 0-4/0-1/51-67/ RBS < 200 mg/dl

Limf/Mon 4,6/7,3 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 EGFR ml/min/1.73 m2

Bilirubin direct <0.25 mg/dl Fe 21 53-167 µg/dl

Bilirubin indirect <0.75 mg/dl TIBC 121 300-400 µg/dl

Gula Darah Sewaktu 93 <200 mg/dl Saturasi 17 16-45%

Transferin
 Laboratory Findings (24/07/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

pH 7,39 7,35-7,45

pCO2 34,7 mmHg 35-45

pO2 165,7 80-100

mmHG
HCO3 21,4 21-28
mmmol/L
 Urinalysis ()
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity 10 x
Color Epithelia ≤1
pH 4.5 – 8.0 Cylinder
SG 1.005 – 1.030 Hyaline
Glucose negative Granular
Protein negative Other
Keton negative
Bilirubin negative 40 x
Urobilinogen < 17 Erythrocyte ≤3
Nitrite negative Leukocyte ≤5
Leukocyte negative Crystal
Erythrocyte negative Bacteria ≤23 x 103/ml
Other
 Blood Gas Analysis (dd/mm/yy)

With Room Air/…. Normal

pH 7.35-7.45
pCO2 35 – 45 mmHg
pO2 80 – 100 mmHg
HCO3 21 – 28 m mol/L
O2 saturation > 95 %
BE (-3) - (+3) m mol/L
Temperature
Hb
Conclusion:
 Ascites Fluid Analysis (//)
LAB NORMAL LAB VALUE NORMAL
Macroscopic Protein Total < 3 g/dL
Colour Glucose > 60 mg/dL
Clot Trigliserida Chylous >110 mg/dL
Pseudochylous <50
mg/dL
Clarity Cholesterol Transudat >45-60 mg/dL
Exudat <45-60 mg/dL
LDH Transudat <320 U/L
Exudat >320 U/L
Erythrocyte count /µL
Leucocyte count /µL
PMN %
MN %
Electrocardiography (24/07/2019)
 Electrocardiography ()
• Sinus rhythm, HR 78 bpm regular
• Frontal Axis :
• Horizontal Axis :
• P wave : Normal ( <0,12 second, < 0,3mv)
• PR interval : Normal (0,12 second)
• QRS complex : Normal (0,08 second )
• Q wave : Normal ( < 0,04 second)
• QT interval : Normal ( 0,36 second)
• QT interval corrected :
• ST segment : Normal
• Others :

Conclusion :
Thorax X-Ray (/07/2019)
Thorax X-Ray (30/06/2019)
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
Problem Analysis
 Risk Factors Analysis

Problem Theory Patient

Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis

Problem Theory Patient

Key Message Management
Key Message Social
Condition This Morning
 Prognosis

• Ad vitam :
• Ad functionam :
• Ad sanationam :