MORNING REPORT

Date : 6th September 2021

Physician in charge
IA : dr. Niko, dr. Reyhan
IB : dr. Adam
II HCU : dr. Dandi
II Medical Consultation : dr. Jonny
II Incovit : dr. Dheni
II IGD : dr. Ros, dr. Helsa
II IGD Incovit : dr. Akbar
Chief on duty : dr. Ajeng
Consultant on duty : dr. Laksmi Sasiarini,Sp.PD-KEMD
Facilitator : dr. Laksmi Sasiarini,Sp.PD-KEMD
 Summary of Database
Mrs. M / 86 yo / ward 28
Heteroanamnesa
Chief Complaint:
Gangrene of the right hand
History of Present Illness:
• Gangrene of the right hand was complained since 2 weeks ago. At the start, her right
forearm was injured, become swollen, hitted by fallen desk that happened 3 weeks ago.
She and her family did not seek treatment well for the injury, so it became blackened,
started from the finger tip, and rapidly spread up to her right elbow, and it really made
her suffering from pain.
• Yesterday, she was taken to the ER, treated by Orthopedic & Traumatology Department,
having amputation of her right forearm. Pain was complained after the surgery.
• Diagnosed with hypertension since 15 years ago, but never been consuming drug
routinely.
• History of diabetes was denied. There was no shortness of breath nor cough.
 Summary of Database
Past Medical History:
There was no past medical history being recorded.

Family History:
There was no history of diabetes, or hypertension in his family.

Social History:
She is a widow. She had 2 children, that already died. She is now living and taken care
by her granddaughter and grandson-in-law.

Review of System:
Low intake (+)
Hard to sleep (+)
Weak energy (+)
Memory decline (+)
 Physical Examination
General appearance looked moderately ill Sat O2 96 % RA, VAS 6 / 10
GCS E4V5M6 compos mentis
BW: 40 kg; BH: 155cm; BMI: 16,6 kg/m2 (underweight)
BP 172/93 mmHg PR 96 bpm regular strong RR 20 tpm Tax 36,8 oC
Head Anemic conjunctiva(-)
Neck JVP R+2 cmH20
Chest symmetrical
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space tympany

Extremities Edema (-), pale (-), MMT 5 | 5, amputated right forearm with bandage (+)
5|5

Urination UOP = 1,1 cc/kgBW/hr

 CLINICAL APPEARANCE
Before surgery After surgery

Gangrene

03/09/2021 05/09/2021
 Laboratory Findings (04/09/21)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 20.930 4.700 – 11.300 /µL Ureum 42,5 20-40 mg/dL
Hemoglobine 12,9 11,4 - 15,1 g/dl Creatinine 0,32 <1,2 mg/dL
PCV 37,9% 38 - 42% BUN/Cr 19,85

Thrombocyte 297.000 142.000 – 424.000 /µL

Eo/Bas/Neu/ 0,2/0,1/85,6/ 0-4/0-1/51-67/ RBS 159 < 200 mg/dl
Limf/Mon 8,4/5,7 25-33/2-5
PPT 10,4 9.3-11.4 detik
SGOT 49 0-40 U/L APTT 21,4 24.8-34.4
SGPT 57 0-41 U/L INR 1,00 0.8-1.30
Albumin 2,91 3.5-5.5 g/dL Rapid antigen Negative
SARS CoV2
Natrium 134 136-145 mmol/L Lactat acid 2,2 0,5-2,2 mmol/L
Kalium 3.07 3,5-5,0 mmol/L

Chlorida 103 98-106 mmol/L

 Blood Gas Analysis (04/09/21)

With NRBM 10 lpm Normal

pH 7,49 7.35-7.45
pCO2 34,5 35 – 45 mmHg
pO2 121 80 – 100 mmHg
HCO3 26,7 21 – 28 m mol/L
O2 saturation 99,3% > 95 %
BE 3,2 (-3) - (+3) m mol/L
Temperature 37,0 0C
Hb 11,4 mg/dl
Conclusion: BGA is within normal limit
Electrocardiography (04/09/2021)
Electrocardiography (04/09/2021)
 Electrocardiography ( 04/09/2021)
• Sinus rhythm, HR 89 bpm regular
• Frontal Axis : Normal Axis
• Horizontal Axis : Normal Axis
• P wave : 0,04 sec
• PR interval : 0,08 sec
• QRS complex : 0,08 sec
• QT interval : 0,40 sec
• ST segment : Isoelectric
• T wave : inverted at lead II, III, aVF, V1-
V5
Conclusion : Sinus Rhythm with HR 91 bpm,
T inverted II, III, aVF, V1-V5
Chest X-Ray (04/09/2021)
RSSA
 Chest X-Ray (04/09/2021)
RSSA

• AP position, symmetric, high KV, Enough inspiration

• Soft tissue was normal and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovascular pattern was Normal. No visible infiltrate, cavity or nodules.
• Cor: site Normal, shape Normal, Size Normal

Conclusion:
- Suspect of Pneumonia
- Sclerotic aorta
- Spondylosis at thoracolumbalis
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. M / 86 yo / ward 28 bed 10 1. Chronic limb - - Non-Pharmacology : PMo :

Subjective threatening - Bedrest S, VS, VAS
ischemia + - Liquid diet 6x200 cc,
Gangrene of the right hand (+) Osteomyelitis gradually increase to soft PEdu:
Amputated right forearm (+) Regio diet 1700 kcal/day, Low Educate
Antebrachii D Natrium < 2 gr/day about the
Pain after the surgery (+) Post Amputatum prognosis of
Pharmacology : the patient
Objective : • IV. Ceftriaxone 2x1 gr
Ext: amputated right forearm • IV Levofloxacine 1x750 mg
with bandage (+) • PO Cilostazole 2x100 mg
• Drip Fentanyl 10 mcg/jam ~
Laboratory (Anesthesiology
- Department)

X-Ray Antebrachii-Manus D +
Elbow
• Suspect of Osteomyelitis
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. M / 86 yo / ward 28 bed 10 2. Hypertension 2.1. Primary - Non-Pharmacology : PMo :

Subjective stage 2 - Bedrest S, BP
- Liquid diet 6x200 cc,
Diagnosed with hypertension gradually increase to soft PEdu:
(+) diet 1700 kcal/day, Low Educate
Natrium < 2 gr/day about the
diagnosis of
Objective : Pharmacology : the patient,
BP: 172/93 mmHg - PO Ramipril 1x5 mg and the
- PO Amlodipin 1x10 mg compliance
Laboratory to take
- medicine
routinely
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. M / 86 yo / ward 28 bed 10 3. CAP PSI 86 - Sputum Non-Pharmacology : PMo :

Subjective RC III culture + - Bedrest S, VS
DST - Liquid diet 6x200 cc,
gradually increase to soft PEdu:
Objective : diet 1700 kcal/day, Low Educate
- Natrium < 2 gr/day about the
diagnosis
Laboratory Pharmacology : and
- • IV. Ceftriaxone 2x1 gr prognosis of
• IV Levofloxacine 1x750 mg the patient
CXR Educate the
- Suspect of Pneumonia patient and
family to use
mask
correctly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. M / 86 yo / ward 28 bed 10 4. Mild - - Non-Pharmacology : PMo :

Subjective hypokalemia dt - Bedrest S, VS, ES
low intake - Liquid diet 6x200 cc,
Low intake (+) gradually increase to soft PEdu:
diet 1700 kcal/day, Low Educate
Objective : Natrium < 2 gr/day. Extra about the
- Kalium diagnosis
and
Laboratory Pharmacology : prognosis of
Natrium: 134 - the patient
Potassium: 3,07
 POMR (Problem Oriented Medical Record)

CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. M / 86 yo / ward 28 bed 10 5. Geriatric problem - - Non-Pharmacology : PMo :

(inanition, - Bedrest S, BMI
Subjective
imobilization, - Liquid diet 6x200 cc,
Low intake (+) infection, gradually increase to soft
malnutrition) diet 1700 kcal/day, Low
Hard to sleep (+) Natrium < 2 gr/day. Extra
Weak energy (+) Kalium
PEdu:
Memory decline (+) Pharmacology : Educate
- about drink
Objective high
BMI: 16,6 kg/m2 (underweight) nutritious
food to
support his
Laboratory nutrition
Albumin : 2,91 gr/dl
 Problem Analysis
Risk Factors
(Age, Falling)

Infection

Decrease of Geriatric
CAP Falling
immunity problem

Increased
Decreased of appetite
Catabolism

General Wound
Hypoalbuminemia
weakness

Reduced Intake
Osteomyelitis

Malnutrition Chronic Limb

Threatening
Ischemia
Key Message Etiology
Key Message Diagnosis
Key Message Management
Key Message Diagnosis
Key Message Management
 Key Message Management

Boyiadzis, Frame, Kohler, Fojo. McGraw-Hill Education. Hematology Oncology Therapy. Second Edition. New York:; 2014
 Key Message Social

• Good emotional support from the family, healthcare provider,

and spiritual support must be given to the patient.
• Educate the family and the patient that current condition is
most of because of the geriatric problem that she’s been
dealing.
• Keep the lines of communication open for patient, family and
healthcare provider.
• Anticipate possible physical changes with acceptance,
optimistic and keep in faith to survive.
• Taking all therapies that’s been given and knowing about the
disease, complication and prognosis.
 Prognosis

• Ad vitam : dubia ad bonam

• Ad functionam : dubia
• Ad sanationam : dubia ad bonam
 Condition This Morning

• GCS: E4VxM6
• BP: 178/95 mmHg
• PR: 98 bpm
• RR: 20 tpm
• Tax: 36.7 C
• Spo2 : 98 % RA
• VAS: 5/10