Summary of Database

Mrs. N/ 50 yo/ ward 28

Autoanamnesis
Chief Complaint:
Painless intermittent bloody urine
History of Present Illness:
• Painless intermittent bloody urine was present since 2 years ago and worsened 5 days before
admission. Bloody color was present during the whole voiding session. There was no bloody discharge
outside voiding session. The symptom was not alleviated with adequate fluid intake. The symptom
was not accompanied with fever, nor there was history of trauma. There was history of blood
transfusion from the previous hospital admission.
• Voiding was usually dribbling, with the feeling of incomplete voiding. There was usually feeling of
distended bladder present for the whole day. These symptom was present for the last 2 years
• Patient suffered from Diabetes since 6 years ago. She routinely took glibenclamide since 4 years ago.
Her highest blood sugar was 700 mg/dL. Prior to the diagnosis of the Diabetes, there was frequent
voiding at night, with frequently unquenchable thirst. There was significant loss in body weight 3 years
ago, around 10 kg in 3 months.
 Summary of Database
Past Medical History:
There was no significant past medical history of hospitalization
Family History:
Her father and eldest brother has Diabetes but not routinely controlled. There was no
other chronic disease, hypertension or known cancer from her mother, eldest brother nor her
second brother.
Social History:
She was married at the age 15, she has 2 children. She lives with her husband, a farmer,
and both of her children. Her eldest son was 16 years old this year. Her daughter was 13 years
old. Her husband has been a heavy smoker since before they got married. She frequently
helped her husband with his field work, including spraying pesticide and fertilizer.
Review of System:
Patient’s urine volume was about 50 cc each day. She ate 2-3 times a day, around half a
plate of rice usually with tempeh, tofu or fried egg. Since the last week she only took around 6
spoonful of rice everyday
 Physical Examination
General appearance looked moderately ill Sat O2 99% on RA
GCS 456 Compos Mentis BW 40 kg Height 150 cm BMI 17.8 kg/m2
BP 129/77 mmHg PR 76 bpm regular strong RR 20x tpm Tax 36.0 oC
Head Slightly Anemic Conjuctiva (+) , Pterygium OS
Neck JVP R+ 2 cmH20 30 degrees
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular| Vesicular
-| - -|-
Sonor | Sonor Vesicular| Vesicular
-| - - |-
Cardio Ictus cordis visible, palpable at ICS V MCL (S)
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular, murmur (-), gallop (-)
Abdomen Flat, Soefl, Bowel Sound (+) normal
Lien/ unpalpable, Traube space tymphany
Liver/ unpalpable, liver span 8 cm
Palpable solid rubbery irregular mass at left inguinal to suprapubic with no clear
border, 10x4 cm in size, painful when pressed (VAS 4/10)
Foley catheter (+) reddish brown urine with blood clot at urine bag
Extremities Warm acral, MMT 5 | 5 , edema (-)
5|5
 Laboratory Findings (24/2/2021)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 6.350 4.700 – 11.300 /µL Ureum 12,2 20-40 mg/dL
Hemoglobine 11 11,4 - 15,1 g/dl Creatinine 0,50 <1,2 mg/dL
HCT 32,50 38 - 42% GFR 112,851 >90 mL/min/1.73 m2
Thrombocyte 285.000 142.000 – 424.000 /µL Natrium 140 136-145 mmol/L
MCV 79,30 80-93 fl Kalium 3,18 3,5-5,0 mmol/L
MCH 26,80 27-31 pg Chlorida 106 98-106 mmol/L
Eo/Bas/Neu/ 2,5/ 0,5/ 62,0/ 0-4/0-1/51-67/ PPT 10.9 9.3-11.4 second
Limf/Mon 24,9/ 10,1 25-33/2-5 APTT 25.3 24.8-34.4 second
NLR 2,49 INR 1.05 0.8-1.30
ALC 1.580 Calcium 8,2 7,8-11,0 mg/dL
SGOT 18 0-40 U/L Phosphor 3,2 2,7-4,5 mg/dL
SGPT 9 0-41 U/L CRP 0,97 < 0,3 mg/dL
Albumin 3,25 3.5-5.5 g/dL ECLIA Non-reactive
Bilirubin Total 0,20 < 1,0 mg/dL D-Dimer 0,70 ≤≤ 0,5 mg/L FEU
Bilirubin Direct 0,10 < 0,25 mg/dL CEA 14,94 < 5,0 ng/dmL
Bilirubin Indirect 0,10 < 0,75 mg/dL CA 125 11,42 < 35 U/mL

Pro-Calcitonin 0,06 < 0,5 low risk for severe CA 19-9 2,12 < 27 U/mL
sepsis/septic shock
 Urinalysis (24/2/2021)
LAB VALUE LAB VALUE
Turbidity Cloudy Microscopic
Colour Reddish Epithelia 2-3
pH 7.5 Cylinder Negative
SG 1,015 Hyaline -
Glucose +3 Granular -
Protein +3 Leukocyte Full
Ketone urine Negative Erythrocyte Full
Urobilinogen Negative Eumorphic 90%
Bilirubin Negative Dysmorphic 10%
Leucocyte 3+ Bacteria Positive
Nitrite Negative
Erythrocyte 4+
 Blood Gas Analysis (24/2/2021)
Lab Value Normal Value
pH 7,43 7,35 - 7,45 mmHg
pCO2 40,1 35 – 45 mmHg
pO2 84,6 80 – 100 mmHg
Bicarbonate (HCO3) 26,7 21 – 28 mmHg
Base Excess (BE) 2,2 (-3) – (+3)
O2 Saturation 96,6% >95%
Hb 7,6 g/dL
Temperature 37,0oC

Conclusion: Normal
Electrocardiography (24/2/2021)
 Electrocardiography (24/02/2021)

• Rhytm : Sinus
• Rate : 74 bpm
• Frontal Axis : normal
• Horizontal Axis : Normal
• P wave : 0.08 s
• PR interval : 0.16 s
• QRS complex : 0.08 s
• QT interval : 0.32 mm/s
• ST segment : isoeletric
• T wave : Upright

Conclusion : Sinus Rhytm 100 bpm

Abdominal Ultrasonography (24/2/2021)
 Abdominal Ultrasonography (24/2/2021)
Hepar: Normal size, regular surface, normal homogeneous echoparenchym, portal/vascular/ system
not widened. Doesn't look nodules/cystsVesika Velea: Normal size, regular walls do not thicken, do
not appear stone
Pankreas: Normal size and echoparenchym, not visible pathological lesions
Lien: Normal size, regular surface, homogeneous echoparenchym, non-dilated lienalis vein
Ren D: Normal size 10.04 cm x 5.12 cm, normal echo cortex, non-widening pelviocalyceal system,
stone/cyst/nodule (-)
Ren S: Normal size 9.52 cm x 5.60 cm, normal echo cortex, non-dilated pelviocalyceal system,
stone/cyst/nodule (-).
VU: Filled with urine appears attached balloon catheter inside, appear heterogeneous lesions,
hipohipedense, indecisive margin compared to postero-inferior VU with a size of 3.41 cm x 6.50 cm
x 3.06 cm Color doppler technique appears vascularity in some lesions, partly accompanied by a
picture of twin sign, with a change in position does not appear to change the position of the lesion.
There is also thickening of diff vesica urinaria with a thickness of 8.0 mm.
Uterus: Normal size, does not appear pathological lesions
Adnexa D et S: D: cystic lesions appear firm borders with internal echo in it demha size 7.3cm x 7.4
cm with color doppler technique does not appear vascularity in it.
Invisible lymphadenopathy paraaorta and parailiaca right

Conclusion: Diffuse bladder thickening with blood clot suggestive mass dd hemorrhagic cystitis
Complicated cyst susp benign
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. Bladder 2.1 Bladder Urine cytology Non Pharmacology: Subjective, Vital
Mrs. N/ 50 y.o / W 28 Mass + Painless Cancer - Bed rest Sign, UOP,
Subjective intermittent Urine culture - Equal fluid balance Hematuria,
- Painless intermittent hematuria
since 2 years hematuria + 2.2. Chronic and antibiotic - Soft Diet 1800 kcal/day urination
- History of prolonged exposure to elevated CEA cystitis sensitivity test Carbohydrate 55%, Fat patency
15% Protein 20%,
tobacco and organic chemical
- History of blood transfusion Cystoscopy - Consultation to urology
department Education:
Objective Abdominal CT • Educate about
Scan with Pharmacology: the possible
- Slightly anemic conjunctiva contras - IV Ciprofloxacin 2x400 mg diagnosis
- Palpable solid rubbery irregular mass
at left inguinal to suprapubic with no • Educate about
clear border, 10x4 cm in size, painful the diagnostic
plan
when pressed
- Foley catheter (+) reddish brown • Educate about
urine with blood clot at urine bag the prognosis
• Educate about
the plan to
Lab 24/2/2021
consult to
Hb: 11 g/dL Urology dept
MCV/MCH: 79.3/26.8
CEA: 14.94 ng/mL

Urinalysis 24/2/2021
Reddish, Leukocyte full, erythrocyte
full (90% eumorphic)

USG 24/2/2021
Diffuse bladder thickening with blood
clot suggestive mass
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. DM type 2 - - Non Pharmacology: S, FBG and
Mrs. N/ 50 y.o / W 28 underweight - Lifestyle modification 2HPPBG/3
- Soft Diet 1800 kcal/day day
Subjective
- History of DM since 6 years ago Carbohydrate 55%, Fat 15%
Protein 20%, Education:
- History of nocturia, weight loss Educate
and polydipsia Pharmacology: about the
- SC Insulin Detemir 12 IU disease
bedtime
Objective Educate
about the
-BMI 17.8 kg/m2
long term
treatment
Lab 24/2/2021 Educate
RBS 297 mg/dL about
lifestyle
HbA1C: 16.6% modification,
reduce rice
intake, less
sugar
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Hypochromic 3.1 Chronic SI Non Pharmacology : CBC if bleeding
Mr. Pt/ 55 y.o / W 27 Microcytic blood loss TIBC - Extra iron diet persist
Anemia 3.2 related to Transferrin
Subjective
- Painless intermittent malignancy saturation Pharmacology: Education:
hematuria since 2 years
3.3 low intake - • Educate about the
- History of blood transfusion cause of anemia
• Educate about the
risk of severe
Objective
Anemic conjungtiva anemia if bleeding
persist
Lab 24/2/2021 • Educate about the
Hb: 11 g/dL possibility of blood
MCV/MCH: 79.3/26.8 transfusion if
bleeding persist and
Hb level fall to
below 8 g/dL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. Mild 4.1 Low - Non Pharmacology: Albumin
Mrs. N/ 50 y.o / W 28 hypoalbuminemi intake - Extra protein diet
a Education:
Subjective
- Low intake Pharmacology: Educate
about the
Objective disease

Educate to
Lab 24/2/2021 take extra
protein
Albumin: 3.25 g/dL during meal
(red meat)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
5. Mild 5.1 Low - Non Pharmacology: Albumin
Mrs. N/ 50 y.o / W 28 Hypokalemia kalium intake - Extra kalium diet
Education:
Subjective
- Low intake Pharmacology: Educate
about the
Objective disease

Educate to
Lab 24/2/2021 take extra
kalium during
Kalium 3.18 mmol/L meal
(banana,
broccoli)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
6. Adnexal cyst 6.1 cystoma - Non Pharmacology: Albumin
Mrs. N/ 50 y.o / W 28 ovarii - Consultation to OBGYN dept
6.2 chocolate Education:
Subjective
- Low intake cyst Pharmacology: Educate
about the
Objective disease

Educate
about the
USG 24/2/2021 plan to
Complicated cyst susp benign consult to
OBGYN dept
 Problem Analysis

Exposure to
tobacco

Exposure to
BLADDER CANCER Decrease of appetite
organic
chemical

DM type II
Chronic Blood Loss
Chronic Inflammation

HYPOCHROMIC HYPOKALEMIA
ADNEXAL CYST MICROCYTIC ANEMIA HYPOALBUMINEMIA
 Risk Factors Analysis

Problem Theory Patient

Bladder cancer Tobacco exposure Tobacco exposure
Aromatic amine exposure Organic chemical exposure
Polycyclic aromatic hydrocarbon
exposure
Heavy metal exposure
Organic chemical exposure
Genetic
Radiation treatment
Cyclophosphamide chemotherapy
Long term indwelling urinary
catheter
Key Message Pathophysiology
Key Message Diagnosis
Key Message Diagnosis
Key Message Management
 Key Message Social

• Family support is essential as there will be several

diagnostic procedure and therapeutic option
• Educate the family and the patient for the possible
prognosis and complication of the bladder cancer
 Condition This Morning

GCS : 456
Blood pressure : 120/70 mmHg
HR : 72 bpm
RR : 18x/m
Temp : 36.3o C
SpO2 : 99% on Room Air
 Prognosis

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