Wednesday Shift

August 19th , 2020

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

New Patient • 1 patient

Transferred • 2 pasien
Patient

Dead Patient • 0 Patients

 New Patients (18/08/2020)
No Name / Age Assesment

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

MR Facilitator : Dr. dr. Rudiansyah, M.Kes, SpPD, KGH, FINASIM

: Dr. dr. Muh. Darwin Prenggono, SpPD, KHOM,
FINASIM
: dr. Abimanyu, SpPD, KGEH, FINASIM
Supervisor on duty : dr. Fauzia Noor Liani, SpPD
IIB : dr. Charisma Bimara Cozy
IB : dr. Haudhiya
IA : dr. Asri Silva Shorea
 Case Content
Data Base Summary Data Base

Physical Examination Problem List

Laboratory POMR

ECG Progress Note

Chest X Ray Summary of this MR
DATABASE
Identity : Mrs. M/ 56 yo
Chief complaint : bloated stomach

HISTORY OF PRESENT ILLNESS :

 Patients were sent from the Gastro Entero Hepatology clinic with the main objective of pro endoscopy.
The patient was referred from Kapuas Hospital.
 She present complaints of bloated stomach, upper abdominal discomfort and early satiefy, that had
been felt since 1 year of the SMRS. Bloated stomach comes and goes. Usually it appears in the
morning when she wake up and worsened if eat too late. The complaints of bloated are reduced when
she eat. She also often burps when the stomach is bloated.
 She also complained of epigastric pain, was stinging pain and did not spread. This complaint was felt
by the patient since 1 month ago, but for 2 weeks she has no complaints anymore, after she took the
drug lansoprazole and sucralfate.
 She had no complaints of nausea and vomiting. She had uncomfortable stomach if ate something fatty
DATABASE Continued
 She admitted that she has decresed of body weight (lost 7 kg of weight in the past year).
 She did not complained about decreased of appetite. She ate 3 times/day about 10 spoon every meal
plus with a snack. She usually drink as much as 1-1.5 liters per day.
 She did not complain of abnormalities when urinating. She denied sandy urine, and she also denied
burning pain and heat when urinating.
 She did not complain of any abnormal bowel movements. Change of bowel habit was denied by the
patient. The history of bloody stool was denied by the patient, the history of black tarry stool was also
denied by the patient, defecating like goat feces was also denied by the patient. Stool with hard
consistency since 2018, so, she then underwent a colonoscopy. She received and consumed salofak for
almost 1 year. After that, she admitted that there were more complaints. The patient has felt soft stool
for the last 2 months, although sometimes stool its hard. Within a week she admitted that her stool
were soft
DATABASE continued
 She had no complaints about fever, no complaints about coughing, no complaints about
early night coughs and no complaints about night sweats.
 She complained of shortness of breath if she was doing strenuous activity, and sometimes
accompanied with wheezing. She did not complain shortness of breath when resting or
supine position. She admitted that she never woke up in the middle of the night due to
coughing/ shortness of breath.
 She also did not complain of a sore throat.
 She had history hypertension that she had suffered for 20 years ago, but she admitted that
she did not regularly took a treatment. Last treated six months ago with amlodipine 5 mg.
 She was said to have suffered from heart disease but did not receive regular treatment and
the patient forgot the name of the medicine.
Past Medical history
• She had pulmonary tuberculosis 25 years ago and was treated for six months, then relapsed again about 2 years ago for about 12
months of treatment and was declared a pulmonary specialist as cured.
• On February, she are said to have fluid in the right lung, but according to the doctor there is no need to take fluids and no further
treatment is required
• History of using symbicort inh (+) since 3 months ago
• History of taking pain medication (+) paracetamol
• DM (-)

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

Head Pale conjunctiva (-) , sclera icteric (-)

Neck JVP 5+1 cm H2O

Lymph node enlargement (-)

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)

Barrel chest (-)

Chest :
Palpation Percussion Vesicular Rhonchi Wheezing
Lung N N sonor sonor V V - - - -
N N sonor sonor V V - - - -
N N sonor sonor V V + - - -
  Inspection : flat
Abdomen  Auscultation: normal bowel sound
 Percussion : tympani, liver span 8 cm
 Palpation: epigastric pain, hepar, spleen and mass not palpable, CVA tenderness (-)

Extremities oedema (--/--), warm (+/+)

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

nFBG 134 <200.00

Liver and Biliary

SGOT 36 5.0 – 34.0

SGPT 22 0 - 55.0

Kidney
Ureum 17 0 – 50.0
Creatinine 0.64 0.72 – 1.25
Electrolytes
Natrium 141 136-145

Kalium 3.4 3.5-5.1

Chloride 105 98-107

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

Albumin 4.2 3.5-5.2

Liver and Biliary

Anti HIV Rapid Non Reactive Non Reactive

HBsAg Non Reactive Non Reactive

Anti HCV Non Reactive Non Reactive

ECG (18/08/2020)
ECG INTERPRETATION
Sinus Rhytme Q wave : normal

Regular QRS Complex : 0.04 s

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 (+)

PR interval : 0.20 s Conclusion : Sinus Rhytme,HR 88 bpm, LVH, LAD

Interpretation CXR
(06/08/2020)
Trachea in the middle
The phrenicocostalis sinus dextra is blunted
Hemidiaphragm S was dome shaped
Normal skeletal bone
Pulmo : Increasing bronchovascular pattern,
infiltrate lobus superior pulmo bilateral, Nfibrotic
(+)
Cor : CTR > 0.5, Cardiomegaly

CONCLUSION :

 TB Pulmo bilateral ???

 Efusi pleura Dextra
Cardiomegaly
Colon in Loop
(22/11/2018)
• Contrast barium fills the rectum and reflux of
the sigmoid colon, the descending and
transverse colon and the ascending colon
• Redundancy of the sigmoid colon
• Normal caliber, smooth walls, reduced
frustration, especially colon descendens
• Not visible filling defect / add defect
• Contrast-extrapasase was not seen
• Impression:
• Colitis
• There was no visible intraluminal mass in the
colon / rectum
• Sigmoid redundancy
MSCT Scan Thorax twith
& without contrast
( 29/05/2019)
• Mediastinum Window:
The cast is not enlarged, the aorta is calcified, not dilated
Right pleural intracavum free fluid was seen (50 cc) with thickening
of the pleura and consolidation of the surrounding lung
Neither tracheal-peribronchial nor subcarina KGB hypertrophy was
seen
• Lung Window:
The bronchi of the right and left branches are open, deflecting the
reticular lung with consolidation in both basal and right medius
lobes
There were calcifications, fibrosis and infiltrates in both lungs
There was no visible mass that turned up the contrast
• Conclusion:
Long active KP, with secondary infection (right pleuropneumonia
and bilateral pneumonia)
Aortic atherosclerosis
No intrapulmonary mass was seen
Gen Xpert (12/02/20)
• MTB not detected
USG Thorax Marker dan
Thorax ( 24/02/2020)
• Thorax Ultrasound
• Impression:
Minimal right pleural effusion.
No marker was attached to the right back.
No left pleural effusion was seen
• Thorax PA photo, erect, symmetrical,
inspiration and sufficient condition.
• Impression:
Long active bilateral Pulmo TB
Right pleural effusion
Cardiomegaly
 OMD
( 12/08/2020)
• OMD photos
Contrast appears to fill the
esophagus, stomach,
duodenum
Flat mucosa, normal rugae, no
filling defects / additional
defects were seen
Suspect a major curvature
ulcer
• Impression:
Suspect Major curvature
gastric ulcer
 Summary Database
History Physical Examination Support Examination
 Looked moderately ill  Haemoglobin 13.1  ECG  LVH, LAD
 JVP 5+1 H2O  Leukocyte 3.9  Gen Xpert MTB Not Detected
 Abdominal discomfort  Platelet 186
 BP 160/100 mmHg  OMD (12/08/20)
 Bloating
 Underweight  nFBG 134 • Susp. Ulkus gaster curvature
 Pain-food-released  Rhonki at basal dextra  Ureum 17 mayor
 Epigastric pain  Creatinine 0.64 Thorax Ultrasound
 Natrium 141 Impression:
 Early satiety  Kalium ↓ 3.4 Minimal right pleural effusion.
 Fatty food intollerance  Chlorida 105 No marker was attached to the
 Shortness of breath when heavy activity  Anti HIV Rapid NR right back.
 History of HT since 20 years ago and didn’t  HBsAg NR No left pleural effusion was seen
 Anti HCV NR CXR
routine control Impression:
 History of Lung TB therapy (Category 1 & 2) Long active bilateral Pulmo TB
 History of heart disease and didn’t routin Right pleural effusion
control Cardiomegaly
Colon in loop
 No night sweats Colitis
 No cough There was no visible intraluminal
 Decrease of appetite mass in the colon / rectum
Sigmoid redundancy
 Decrease of body weight 7 kg in 1 years
 Rome 4 Criteria negative
Problem List

Epigastric Pain + Alarm Symptoms

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

 History of HT since 2. Hypertension • Low salt diet < 2 Planning

20 years ago and stage II gram/day monitoring :
didn’t routine control • Candesartan 8 mg 0-0-1  Target BP <
• Amlodipine 5 mg 1-0-0 140/90mmHg
 BP 160/100 mmHg  Lipid Profile
 ECG
 Chest Xray
 Urinalysis
 Renal function
 Funduscopy
 Echocardiograp
hy

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

 Shortness of breath 3. HF stage C FC II • Echocardio Planning

when heavy activity graphy  Low sodium intake < 2 Monitoring:
• NT pro BNP gram/day  Subjective
 History of HT since 20  Vital sign
years ago and didn’t  Management of fluid balance  Sign and
routine control (negative -500/day) symptom

 BP 160/100 mmHg  Management with drugs :

 Mumur sistolik ar mitral  Candesartan 16 mg 0-0-16 Planning Education:
3/6 Give information
 Frimingharm criteria 2 about the disease,
mayor (+) 2 minor (+) prognosis and
therapy
 CXR  Cardiomegaly

 ECG (18/08/20) sinus

rhytme 88 bpm, LVH,
LAD
 Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose Therapy monitoring

 History of Lung TB therapy

(Category 1 & 2)
4. History of 4.1 SOPT CXR Confirmed diagnosed Planning
 No night sweats Lung TB Monitoring :
 No cough
 Decrease of appetite (-) 4.2TB Paru Repeat Gen  Subjective
 Decrease of body weight 7 kg in
1 years relaps Xpert  CXR
 SOB + Wheezing on strained
activi
 Gen Xpert
 Rhonki basal dextra (+) 4.3TB with
 Febris (-)
secondary Planning
 Wheezing (-)
 MSCT Scan Thorax 29/05/19 infection Education
• Long active KP, with secondary
infection (right Educate the
pleuropneumonia and bilateral
pneumonia) patient about
• Aortic atherosclerosis the disease
• No intrapulmonary mass was
seen and how to
 Gen Xpert 23/01/20
treat
• MTB not detected
 Thorax Ultrasound 24/02/20
• Impression:
• Minimal right pleural effusion.
• No marker was attached to the right
back.
• No left pleural effusion was seen
 CXR 24/02/20
 Impression:
• Lung active bilateral Pulmo TB
• Right pleural effusion
• Cardiomegaly
ity
 Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

 Decrease of body 5. Severe  SI • Day 1 Planning

weight Malnutrition  TIBC • 10 kcal/kg/day Monitoring:
 BW 35 kg  Ferritin • 300 kcal/day  Subjective
 BMI 14.3 kg/m3  Total Protein  Vital sign
 Albumin • Day 2-4  BW
 Profil Lipid • 15 kcal/kg/day  Diet recall
• 450 kcal/day  SE
 Phospate
• Day 5-7  Magnesium
• 20-30 kcal/kg/day
• 900 kcal/day Planning
education:
• Day 8-10  Give
• 900 kcal/day or information
increase to full about
requirement malnutrition
 Eat all of
portion of
meals
 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

• Pale conjunctiva (-)

• Abdomen :
•
Progress Note •
Flat
Epigastric pain (+)
19/08/2020 •
•
Liver span 8 cm, tympani
BU (+) N
05.00 • Ekstremities: edema(--/--), warm (++/++)
 Assesment

Epigastric Pain

Progress Note HT Stage II

Progress Note
19/08/2020
04/07/2020
05.00 HF Stage C, FC II

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