MR 190820 Dr. Haudhiya Oke
MR 190820 Dr. Haudhiya Oke
MR 190820 Dr. Haudhiya Oke
MORNING REPORT
PPDS IPD FK ULM
PATIENT’s DATA in Tulip 3rd Floor Ward
TEAM PATIENTS
PDP 11 patients
PDW 6 patients
Isolasi 1 patients
PATIENT’S DATA
1.Epigastric pain
2.HT Stage II
1 Mrs. M/56 yo 3.HF Stage C FC II
4.History of Lung TB
MORNING REPORT
Wednesday, Agustus 19th, 2020
Laboratory POMR
History of Allergy
• The patient has no history of food allergies, environment or drugs
Habit History
• The patient has never exercised
• The patient has no history of smoking
• The patient has no history drinking alcoholic, consume drug (NAPZA), tattoo (-)
• The patient has no history energy drink
• The patient has no history consume of herbal drink
Socioeconomy History
• The patient is a widow, have 2 childrens
• The patient has not worked for a long time
DATABASE
General appearance: looked moderately ill BMI : 14.3 kg/m2 (Under weight)
Height: 145 cm BSA : 1.10 m2
GCS : E4V5M6 Input: 600 cc/8 hours
Weight: 30 kg
Urine Output: 400 cc/8 hours = 1.11 cc/kgbb/hour
BP: 160/100 mmHg PR: 88 bpm, regular, RR: 20 bpm Tax: 36.6 oC SpO2 : 98% on Room air
strong
LHM: ictus not visible, but palpable at ICS V midclavicular line sinistra
Heart RHM: sternalis line dextra
S1-S2 single, regular, murmur (+) sistolik ar mitral (3/6)
Rectal toucher
Spincter ani normal, ampula recti normal, massa (-), tenderness (-), handscoon melena (-), blood
(-), fecess (-)
Clinical Appearance
Laboratory Finding (18/08/2020, 18:00:08) at RSUD
Ulin
Lab Result Value Lab Result Value
Complete Blood Count Differential count
Haemoglobin 13.1 14.0 – 18.0 Basophils % 0.5 0.0 – 1.0
Leukocyte 3.9 4.0 – 10.5 Eosinophils % 0.8 1.0 – 3.0
Erythrocyte 4.57 4.10 – 6.00 Neutrophils % 66.2 50.0-81.0
Haematocrit 39.8 42.0 – 52.0 Lymphocyte % 23.3 20.0 – 40.0
Platelet 186 150 – 450 Monocyte % 9.2 2.8 – 8.0
MCV 87.1 75.0 – 96.0 Basophils # 0.02 <1.00
MCH 28.7 28.0 – 32.0 Eosinophils # 0.03 <3.00
MCHC 32.9 33.0 – 37.0 Neutrophils # 2.59 2.50 – 7.00
RDW-CV 13.7 12.1 – 14.0 Lymphocyte # 0.91 1.25 – 4.00
Monocyte# 0.36 0.30 - 1.00
NLR 2.84
Laboratory Finding (18/08/2020, 18:00:08) at RSUD
Ulin
Lab Result Value
Blood Glucose
SGPT 22 0 - 55.0
Kidney
Ureum 17 0 – 50.0
Creatinine 0.64 0.72 – 1.25
Electrolytes
Natrium 141 136-145
Imuno-Serology
Rapid Test IgM COVID19 Non-Reactive Non-Reactive
Rapid Test IgG COVID19 Non-Reactive Non-Reactive
Laboratory Finding (18/08/2020, 18:00:08) at RSUD
Ulin
Lab Result Value
Albumin
ST segment : normal
Heart Rate 88 bpm
QT interval : 0.40 s
Frontal Axis : Normal axis
Horizontal Axis : Clockwise rotation T wave : T tall (-)
P wave : normal, progressive flattening (-)
Cornell criteria (S V3 + R aVL = 28) LVH (+)
CONCLUSION :
HT Stage II
HF Stage C, FC II
History of Lung TB
Severe malnutrition
Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring
Abdominal discomfort
Bloated stomach
1. Epigastric pain 1.1 Peptic ulcer Endoscopy + • Confirm diagnosed Planning
Pain-food-released
Epigastric pain
+ Alarm disease (gaster) Biopsi • Soft Diet High calory Monitoring:
Early satiety symptoms 1.1.1 H. Pylori CLO test high protein 1800 Subjective
Fatty food intollerance
Deacress of body weight
Infection ( campylobacter kkal/day Vital sign
Nausea (-), vomit (-) 1.1.2 Dyspepsia Light organism • IVFD RL 1500CC/24 VAS
Black tarry stool (-)
Epigastric tenderness Organik test) hours Sign and
Consumed salofak for almost 1
years
1.1.3 Chron’s Histo PA • Inj Lansoprazole symptom
Mass (-) Disease CEA 30mg/24h
OMD (12/08/20): Suspect Major
curvature gastric ulcer PCR • Inj Metoclopramide Planning
Colon in loop (2018) : 1.2 Malignancy Spesimen 10mg/8h education:
• Colitis
• There was no visible intraluminal 1.2.1 Primary biopsi • Po. Sucralfat syrup 4x2 Educate patient to
•
mass in the colon / rectum
Sigmoid redundancy 1.2.2 Metastase Urea breath Cth consume the
ROME IV Criteria (Negative) process test nutrition food not
GERDQ (5 point)
in large portion
and in much time
avoid acid, high fat
and spicy food
Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose Therapy monitoring
Planning
Education
Educate how to
control his blood
pressure and
prevent the
complication
Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose Therapy monitoring
Kalium 3.4 6. Mild 6.1 Renal loss K urine • IVFD RL 1500 cc/24 Planning
Hipokalemia hours Monitoring:
6.2 Low intake SE each 48 day
EKG
Motorik
Planning
education:
Give
information
about
hipokalemia
• Subjective
• Bloating (+)
• Objective
• GCS E4V5M6
• BP 140/90 mmHg
• PR 97 x/Minute
Progress Note • RR 20 x/minute
19/08/2020 • T 36.6 C
05.00
• SpO2 98% on room air
• Urine : 1200 cc/24 h = 1.67 cc/kgbw/h
• Input : 1000 cc/24 h
Physical Examination
Epigastric Pain
History of Lung TB
Severe malnutrition
Planning Therapy
Diet TKTP 1800 kkal/days
IVFD NS 0.9 % 1500 cc/24 hours
Lansoprazole IV 30 gr/24 hours
Progress Note Metoclopramide 1 g/8 hours
Progress Note Po. Sucralfat syr 4 x II Cth
19/08/2020
04/07/2020
05.00
Planning Diagnosed
Endoscopy + Biopsi
Progress Note
CXR
Progress Note
19/08/2020 CT Scan Thorax
04/07/2020
05.00 Repeat Gen Xpert
THEORY & GUIDELINES
PROBLEM
ANALYSIS
EPIGASTRIC PAIN + ALARM
DYSPEPSIA SYMTOMP
ORGANIK PUD
MALIGNANCY
CHRON DISEASE
HISTORY OF TB + RHONKI HT STAGE II
H PYLORY INFECTION BASAL DEXTRA
HF Stage C FC II
SOPT DD TB RELAPS
RISK FACTOR
PAPAPDI
The role of endoscopy in dyspepsia. Gastrointest Endosc. 2015
King M, Kingery JOE, Casey B, College K. Diagnosis and Evaluation of Heart Failure. Am Fam Physician, 85, 2012, pp. 1161-1168.
2016 ESC Guidelines for the diagnosis and treatment of acute
and chronic heart failure
THANK YOU