Dewi - Arum

MORNING REPORT
Friday, 20 September 2019

RESIDENTS IN CHARGE :
IA : dr. Dimas, dr. Haris, dr. Farid, dr. Hani, dr. Caesar (cardio)
II HCU : dr. Affa
II Consulan : dr. Reizal
II Intensive : dr. Arde
II UGD : dr. Arum, dr. Dewi, dr. Ikke
Chief : dr. Eden
Consultant : dr. Dewi Indiastari, SpPD
Facilitator : dr. Didi Candradikusuma, SpPD-KPTI
 RESUME
Admission Discharge MedCon Pass away Remaining Total
2 1 5 2 12 15

Admission
36%

43%
Discharged
Med Con
Passed away
Remaining
0% 14%
7%
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning Ward
Initial Diagnosis
Medical consultation from obsgyn department for Emergency: Planning Diagnosis:- ER
management of hematemesis - endoscopy
Identity : P2 / Mrs.M / 29 years old / 11455626
Primary survey : Urgency : Planning Therapy:
Airway: patent Breathing: spontan Circulation: warm - from OBGIN department
Kaltrofen supp II
Secondary survey : Non Urgency : Dexametason 24mg
Anamnesis : 1. Hematemesis Histolan 3x1
Chief Complain : abdominal pain 1.1 SRMD
Abdominal pain at epigastrium that radiated to back since 1 1.2 PUB From internal medicine
week ago, nausea and vomiting since 3 days ago, contained 2. G2P1001Ab000 30-32 mgg department
food. Difficulty in passing stool since 4 days ago, no history of T/H - fasting
taking jamu nor painkiller drugs. She was pregnant her second 3. Mild hipokalemia - GC/8 jam  1x clear, start fluid
child with 30-32 gestational age. When NGT was inserted, the 3.1 GI loss diet 6x200cc
NGT drainage was black. - bolus lansoprazole 60 mg
continude with drip lansoprazole
Physical Examination 6 mg/jam
Look moderately ill, GCS 456; BP: 116/76 mmHg; HR: 112 - iv metoclopramide 3x10 mg
bpm; RR: 20 tpm; Tax: 36,6 C; SpO2 : 98% RA
Head/Neck : Conj. an (-), ict (-), ed (-), NGT drainage black Ref : PAPDI 2014 Planning Monitoring:
Abdomen : rounded, soefl, BS (+)decreased, meteorismus (+), Subjective, VS, UOP, NGT
Liver span +- 10 cm, Traube's space tympani, tenderness drainage
epigastrium, TFU 4 cm under proc xyphoid
Patient woll be joined care with
Laboratory : CBC 12,9/11280/37,2/249000; MCV/MCH gastroenterohepatology
85,1/29,5; Diff0/0,1/93,6/2,4/3,9; PPT 9,6 (10,9); INR 0,92; division
APTT 28,3 (25,1); OT/PT 45/85; Alb 3,98; GDS 125; Ur/Cr
43,3/0,77; SE 134/3,39/100; UL: BJ>1,030, prot 2+, keton 3+,
bil 2+, blood 2+, 10x: silinder granuler 6-8, ca oxalat
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning Ward
Initial Diagnosis
Medical consultation from obsgyn department for Emergency: Planning Diagnosis:- ER
management of anemia and electrolyte imbalance - -
Identity : P1 / Mrs.S / 48 years old
Primary survey : Urgency : Planning Therapy:
Airway: patent Breathing: spontan Circulation: warm 1. Severe hypokalemia from OBGIN department
1.1 Low intake IVFD NS 20 tpm
Secondary survey : 1.2 GI loss Iv metronidazole 3x500 mg
Anamnesis : fatigue Iv ceftriaxone 2x1 g
Fatigue since 1 week ago. Nausea vomiting every eat and Non Urgency : Iv gentamicin 2x80 mg
drink since 4 months ago, decreased of appetite and body 1. Ca ovarium post surgical Po Sf 2x1
weight drastically. She had got blood transfusion 4 packs staging + chemotherapy
PRC 1 week ago. She was diagnosed with Ca ovarium BEP 6 series From internal medicine
since 1 years ago and had undergone surgery and 2. Surgical wound infection department
chemotherapy. After 1 series of chemotherapy, her 3. Anemia NN Soft diet HCHP, extra kalium
condition became worsened. Since last night, her surgical 3.1 related malignancy Correction of hypokalemia 3
wound secreted pus. 4. Nausea vomiting cycles: Wida KN2 500cc in 4 h
4.1 mass effect Tranfusion of PRC 2 kolf/d
Physical Examination 4.2 paraneoplastic until Hb 10 g/dl
Look moderately ill, GCS 456; BP: 101/70 mmHg; HR: 85 syndrome Iv omeprazole 1x40 mg
bpm; RR: 20 tpm; Tax: 36 C; SpO2 : 100% RA; VAS 7/10 5. Severe cancer pain Iv metoclopramid 3x10 mg
dengan provocation Po MST 2x10 mg

Head/Neck : Conj. an (+), ict (-), ed (-) Planning Monitoring:

Abdomen : rounded, soefl, BS (+)normal, lobulated mass Subjective, VS, VAS, UOP, SE
at all abdominal area, pus (+) at surgical wound post correction, Hb post
transfusion
Laboratory Result : CBC 8,4/9200/25/324000; Ref : PAPDI 2014
MCV/MCH 84,5/28,4; Diff 0/0/80/14,5/5,5; PPT 11,3
(10,9); INR 1,09; APTT 27,9 (25,1); OT/PT 15/9 ; Alb 2,77; Patient will be joined care with
RBS 77; Ur/Cr 38,3/0,74; SE 128/2,17/86; UL dbN hemato-oncology division

ECG: sinus rhythm 92 bpm, flattening T

 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning Ward
Initial Diagnosis
Medical consultation from ENT department for management of Emergency: Planning Diagnosis:- ER
hiponatremia, azotemia, dan increased transaminase - IHK CK, Chromogranin 2,
Identity : P1 / Mr.S / 47 years old
Primary survey :
synapthophisin, repeat USG
Airway: patent Breathing: spontan Circulation: warm Urgency : abdomen
Secondary survey : -
Anamnesis : Planning Therapy:
Chief Complain : chest pain Non Urgency : from ENT department
Chest pain at central area that radiated to back since 1 week ago,
increased when he had cough or took a deep breath. Mild grade fever
1. Ca larynx T3N0M1 O2 tracheal mask 6 lpm
since 1 week ago. Decreased of appetite since 1 week ago, (metastase paru) post Nebul NS + suction
decreased of urination since 1 week ago. history of Ca larynx since 6 trakeostomi dan radioterapi Iv ketorolac 3x30mg
months ago, had undergone tracheostomy and radiotherapy 10 times. 2. Ca ileum T4N1Mx post Iv ranitidin 2x50 mg
The last radiotherapy session was at 23 August 2019. History of ileostomy
laparotomy and ileostomy at 27 August 2019 because of intestinal
perforation. There was malignant cells from the tissue biopsy.
2.1 neuroendocrine carcinoma From internal medicine
Physical Examination 2.2 adenocarcinoma poorly department
Look moderately ill, GCS 456; BP: 107/72 mmHg; HR: 86 bpm; RR: differentiated IVFD NS 1000cc/2 h -> continued
20 tpm; Tax: 36 C; SpO2 : 99% trakeal mask; UOP 500cc/24 h; VAS 3. Severe Cancer pain with NS 1500cc/24 h
8/10 4. Increased transaminase Po MST 2x10 mg
Head/Neck : Conj. an (-), inserted tracheostomy tube
Abdomen : flat, soefl, BS (+)normal, Liver span +- 10 cm, Traube's
4.1 liver metastasis ?
space tympani, tenderness (-), inserted ileostomy 4.2 reactive due to post Planning Monitoring:
Laboratory : CBC 13,2/10760/38,4/316000; MCV/MCH 74,1/25,5; operative Subjective, VS, UOP, VAS, SE
Diff 0,1/0,1/88,8/6,0/5,0; PPT 11,8 (10,9); INR 1,15; APTT 26,5 (25,1); 5. Azotemia prerenal post correction
OT/PT 130/301 ; Alb 4,37; GDS 127; Ur/Cr 90,7 /1,19; SE 5.1 volume depletion
128/4,14/83; BGA 7,41/43,3/55,6/27,4/2,5/88,4% (vein)
CXR (25/7/2019): lung nodules suspect metastasis
6. hiponatremia hipoosmolar Patient will be joined care with
Cervical AP/lat (25/7/2019): opacity at laringeal projection suspect hipovolemia hemato-oncology division
mass 6.1 volume depletion
CT scan head and neck (11/7/2019): solid heterogenous mass at
hypofaring sinistra with size 1,6x1,1x1,1 cm that fixed to plica vocalis
sinistra, inserted trachesotomy at VC 5-6
USG abdomen (24/4/2019): no signs of intraabdominal metastasis
Biopsi subglotis (28/3/2019): malignant epithelial tumor suspect
squamous cell carcinoma
Biopsi ileum (10/9/2019): neuroendocrine carcinoma DD
adenocarcinoma poorly differentiated, tumor invades serous layer, Ref : PAPDI 2014
infiltration 2 lymphnode