dr.

Firman

MORNING REPORT
Date : Thursday, April 1rd 2021

Physician in charge
I : dr. Nanda, dr. Vidi, dr. Puput
II Konsulan : dr. Dandi
II HCU : dr. Firman
II Incovit : dr. Mazen
II UGD : dr. Mira, dr. Rezdy
II UGD Incovit : dr. Gunawan
Chief on duty : dr. Dinda
Consultant on duty : Dr. dr. Supriono Sp.PD-KGEH
Facilitator : Dr. dr. Supriono Sp.PD-KGEH
 Summary of Database
Mrs. U/ 39 years old / W 26

Chief Complaint: Shortness of Breath

History of Present Illness:

• Patient came to the ER complained about shortness of breath since 1 week before
admission. Shortness of breath became triggered with activity and relieve with rest. Patient
sleep with 2 -3 stakes of pillows. He sometimes awake at midnight because of shortness of
breath. Patient also easy felt fatigue since 1 weeks ago. But The shortness of breath was
relieved.
• She also complained about bilateral leg swelling since one week ago.
• She also complained non productive cough since 3 days ago. There was no fever.
• She complained nausea vomiting 2-3 times in a day contained fluid and residual of food.
• She was diagnosed had Hypertension since 2 years ago after the labor. Shee didn’t
routinely took the medication
 Summary of Database
Past Medical History:
Diagnosed HT since 2 years ago

Family History:
Her father had hypertension and DM history, no other disease

Social History:
She married and live with his wife and 2 children

Review of System:
Patient urinate was decrease the urination since 1 weeks ago.
 Physical Examination
General appearance looked moderately ill Sat O2 98%, with Non Rebreathing Mask
GCS 456
BP 146/86 mmHg HR 97 bpm regular strong RR 22tpm Tax 36,7oC
Head Conjuctiva Anemic (+) BW : 89 kg H : 163 cm BMI 33
Neck JVP R + 4 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor |sonor Vesicular | Vesicular
+| + - |-
Cardio Ictus invisible, palpable MCL (S) AAL V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm
Lien/ Traube space tympany
Extremities Edema (+) pitting, pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-)
 Laboratory Findings (31/03/2021)
LAB VALUE NORMAL

Hemoglobin 7,0 11,4 - 15,1 g/dl

Leucosit 9.370 4.700 – 11.300 /µL
PCV 21,2 38 - 42%
Thrombocyte 257.000 142.000 – 424.000 /µL
MCV 77,7 80-93 fl
MCH 25,6 27-31 pg
Eo/Bas/Neu/Limf/Mon 0,6/0,1/83,8/11,8/3,7 0-4/0-1/51-67/25-33/2-5
Natrium 137 136-145 mmol/L
Kalium 6,87 3,5-5,0 mmol/L
Chlorida 101 98-106 mmol/L
Random Blood Sugar 103 < 200 mg/dl
Albumin 3,7 3,5-5,5
Laboratory Findings (31/02/2021)
LAB VALUE NORMAL
Ureum 214,2 16,6 – 48,5
Kreatinin 20,02 <1.2
eGFR 1,893 ml/minute/1,73m3
Calcium 4,8 7,6-11,0mg/dl
Phosphat 9,9 2,7-4,5mg/dl
Electrocardiography (31/03/2021)
 Electrocardiography (31/03/2021)
• Sinus rhythm, HR 91 bpm regular
• Frontal Axis : normal
• Horizontal Axis : clockwise rotation
• P wave : normal
• PR interval : 0.08”
• QRS complex : 0.08”
• Q wave : no pathological Q
• QT interval : 0.48”
• ST segment : isoelectric

Conclusion : Sinus Rhythm 91 bpm, Prolonged QT interval,

QT Corrected 594ms
Chest X – Ray 31/03/2021
 Chest X – Ray 31/03/2021

• AP position, symmetric, enough KV, less inspiration

• Soft tissue was thin and bone was normal
• Trachea was in the middle
• Hemidiaphragm D and S were dome-shaped
• Phrenico-costalis angle D and S was dull
• Pulmo: bronchovesicular pattern was increased with
perivascular infiltrate, with batwing appearance
• Cor: site N, size CTR 70%, shape N, elongation aorta (-), cardiac
waist (-)

Conclusion: Cardiomegaly, Pulmonal congestive, Pneumonia

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

1. CKD st 5 Newly 1.1 Abdominal Non Pharmacology: PMo

Mrs. U/ 39 years old DIagnosed Glomerulonephr USG - Diet renal 1700 kkal/day, BP, UOP
Subjective itis chronic low sodium <2gr/day,  
• SOB since 1 week protein 1-1,2 Pedu
• Decrease of urination since 1.2 gr/kgBW/day Educate the
one week Hypertension - O2 NC 2-4lpm patient about
• History of HT since 2 years ago Nephrosclerosis the cause of
Pharmacology : CKD.
Objective - HD Elective Educate
• BP 146/86 mmHg about Double
Lumen or AV
• Anemia Conjungtiva (+) shunt, CAPD
insertion or
Laboratory renal
- UR/CR : 214,1 / 20,2 mg/dL transplantatio
- eGFR: 1,893 ml/menit/1,73 m2 n
- Hb 7,0 g/dL
- Calsium 4,8
- Phospor9,9
- Kalium 6,87

CXR
Cardiomegaly, Pulmonal congestive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

2. HF St C FC 2.1 CRS type IV Echocardio Non Pharmacology Pmo

Mrs. U/ 39 years old III graphy - Bed rest Semi fowler S,VS, SpO2
2.2 HHD NT-Pro BNP position
Subjective
- 02 NRBM 10 lpm Ped:
Educated
• Shortness of breath since 1 week Pharmacology diagnostic
ago, DOE (+), Orthopnea (+) - IV Furosemide 3x40mg about Heart
• History of HT since 2 years ago - PO Ramipril 1x10mg Failure
Objective :
Educated
BP: 146/95 mmHg about
H/N : JVP R+4 cm H2O compliance
Thorax : Rhonki +/+ at basal pulmo drug therapy
and limitation
Edema extremity inferior bilateral (+) activity
Chest Xray:
Pulmonal congestive
Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

3. Severe 3.1 decrease of - Non Pharmacology: PMo

Mrs. U/ 39 years old Hyperkalemeia renal excretion - Diet renal 1700 kkal/day, SE ECG Post
low sodium <2gr/day, corection
Laboratory
- UR/CR : 214,1 / 20,2 mg/dL
protein 1-1,2
- eGFR: 1,893 ml/menit/1,73 m2
gr/kgBW/day, low Education:
- Kalium 6,87
potassium diet The cause of
Hyperkalemia
Pharmacology : can cause by
ECG
Sinus Rhythm 91 bpm, Prolonged
- HD Elective Renal
- Corection Hyperkalemia 3 Impairment
QT interval, QT Corrected 594ms cycle Ca Gluconas 1gr +
D40% 2 flash + Insulin
10unit
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

4. CKD MBD - - Non Pharmacology: PMo

Mrs. U/ 39 years old - Diet renal 1700 kkal/day, Calsium
low sodium <2gr/day, Phospor post
Laboratory
- UR/CR : 214,1 / 20,2 mg/dL
protein 1-1,2 correction,
- eGFR: 1,893 ml/menit/1,73 m2
gr/kgBW/day, low dietary PTH
phosphate
- Calsium 4,8
Education:
- Phospor 9,9
Pharmacology : The cause of
- Kalium 6,87
- HD Elective CKD MBD can
- Corection Hypocalcemia cause by
Ca Gluconas 2gr in 100 cc Renal
NS in 1 hour, repeated Impairment
every 6 hour unti Ca level
>7
- PO CACO3 3x500mg
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
5. HT on (-) - Non Pharmacology: S, Blood
Mrs. U/ 39 years old
treatment - Diet renal 1700 pressure
Subjective kcal/day, low sodium
• History of hypertension <2gr/day, protein 1- Education:
since 2 years ago 1,2 gr/kgBW/day Educate the
• Her father had patient
hypertension history Pharmacology : about
- PO Ramipril 1x10 mg hypertensio
Objective : n, and how
• BP : 146/86 mmHg to manage
it with diet
control and
good
medication
compliance
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
6. Anemia 6.1 FE SI, TIBC, Non Pharmacology : S,VS, Dl
Mrs. U/ 39 years old
hypochrome deficiency ferritine (-) post
mycrocytic 6.2 Chronic transfusion
Subjective
Inflamation Pharmacology :
Patient felt easy to become Transfusion PRC 1 pack/day Ped:
fatigue until HB level > 8 Educated
Plan to give EPO if Ferritin > diagnostic
Objective 100, SI > 100, TIBC > 20% about
Conjungtiva anemia (+)
Anemia
that caused
Laboratory by CKD
Hb 7,0 g/dL
MCV/MCH: 77,7/25,6
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL Idx PDx PTx PMo&Ed
7. Nausea 7.1 Uremic Non Pharmacology: Pmo:
Mrs. U/ 39 years old
Vomiting Gastropaty - Bed rest Nausea and
Vomiting
Subjective 7.2 PUD Pharmacology:
- IV Metoclopramide Ped:
Nausea vomiting 2-3 times in a
3x10mg The
day contained fluid and residual - HD Elective complained
can caused
of food. by Renal
Laboratorium: Impairment
- UR/CR : 214,1 / 20,2 mg/dL
- eGFR: 1,893 ml/menit/1,73
m2
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

8. Pneumonia Sputum Non Pharmacology S,VS, SpO2

Mrs. U/ 39 years old CAP PSI risk culture and - Bed rest Semi fowler
score drug position Ped:
Subjective sensitivity - 02 NC 2-4lpm Educated
diagnostic
• Shortness of breath since 1 week Pharmacology about
ago - IV Levofloxacin 750mg -> Pneumonia
• Acute non Productive cough since 500mg/48 hour
3 day ago - PO NAC 3x200mg
Objective :
RR 22 tpm
SpO2 99% with NC 2-4 lpm
Thorax : Rhonki +/+ at basal pulmo
PSI risk score
Chest Xray:
Pneumonia, Efusi pleura bilateral
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

9. Obesity Non Pharmacology BMI, TB, BB

Mrs. U/ 39 years old grade 1 - Diet and life style
modification Ped:
Objective :
BB : 89kg Educated to
life style
TB : 163cm modification
BMI : 33
 Problem Analysis
Anemia

Decrease EPO Production

Hyperkalemia Shortened RBC survival

True Iron Deficiency

1. Decrease renal excretion Bone marrow suppression

2. Impaired renin secretion
1. Gromerular hypertrophy
2. Mesangeal expansion
CKD St 5 3. Tubulointerstitial fibrosis
4. Gromerulo-sclerosis
Uremic gastropathy
RAAS
Nausea
Hypertension
Increase venous return

Increase cardiac workload

Pneumonia
Heart Failure
 Risk Factors Analysis

PROBLEM THEORY FACTUAL

CKD st 5 Risk Factor of CKD that
undergone HD Hypertension
Glomerulonefritis Obstruction
Diabetes Melitus
Obstruction and infection
Hypertension
Other Causes

PAPDI
 Risk Factors Analysis

PROBLEM THEORY FACTUAL

Heart Failure Risk Factor of HF :
Coronary artery disease Hypertension
Hypertension Ageing
Cardiomyopathy Physical Inactivity
Valvular heart disease
Congenital heart disease
Arhtymia
Diabetes mellitus
Ageing
Smoking & tobacco
Infection
Obesity
Physical inactivity
Heredity

AHA
 Management Analysis

Problem Theory Patient

CKD stg V 1. Renal Replacement Terapy 1. HD routine

2. targeting BP ≤140/90 mm Hg if no
proteinuria 2. targeting BP ≤130/80 mm
Hg if proteinuria
3. Avoiding high protein intake (>1.3 g/
kg/day) in adults with CKD at risk of
progression.
4. lowering salt intake to <2 gram per day
of sodium ( corresponding of 5g salt)
Slow down the disease
progression
Renal Diet 1800kCal/ day,
Low salt diet<2g/day, protein
0,6-0,8 g/body weight/day
Prevent and treatment of
cardiovascular disease

PAPDI
 Management Analysis

PROBLEM THEORY FACTUAL

Management of Heart Failure

On this patient :
• The need to perform thorax rontgent,
- Bed rest, semifowler
echocardiography, and BNP
position
• Oral Diuretic or Parenteral Diuretic is the main - Low salt diet < 2 gram/
Heart failure Stg treatment in patient with heart failure
day
C FC III • Low dose ACE inhibitor or ARB may begun - Inj. Furosemide 3x40
when the patient euvolemic
mg
• Low dose beta blocker until optimal dose of
beta blocker can begun after diuretic and ACEi or
Po : PO Ramipril 1 x 5mg
ARB given to the patient PO Clonidin 3x0,15mg
PAPDI
Key Message Management
Key Message Management
 Key Message Social

• Patient with chronic hypertension and chronic

kidney disease can be educated for the compliance
of the drugs and haemodyalisis schedule
• Good emotional support from the family, health care
provider, and spiritual support must be given to the
patient
 Condition This Morning

• GCS 456
• BP : 140/78 mmHg
• HR : 86 bpm
• RR : 20 tpm
• Tax : 36.4 C