MORNING REPORT

dr. Dandi
Date : September, 5th 2021

Physician in charge
I : dr. Reyhan, dr. Niko, dr. Devina, dr. Adam
II Consult : dr. Jonny
II HCU : dr. Dandi
II Incovit : dr. Dheni
II UGD : dr. Ros, dr. Helsa
UGD Incovid : dr. Akbar
Chief on duty : dr. Ajeng
Consultant on duty : dr. Laksmi Sasiarini SpPD-KEMD
Facilitator : dr. Laksmi Sasiarini SpPD-KEMD
 Summary of Database
Mr. A/ 45 yo/ward 26
Heteroanamnesa
Chief Complaint: Decreased of consciousness
History of Present Illness:
• Patient was admitted to the hospital due to decreased consciousness gradually and worsened since one day
before admission. Initially, he was unable to communicate, then he slept and did not weak up.
• He also complained fever since 3 days before admission and didn’t relieve with paracetamol
• He also had diarrhea since 3 days before admission, 2-3 times per day and the volume was about 50-100cc
in each diarrhea. The diarrhea contained yellow feces with mucus and blood
• He had the history of hypertension since 15 years ago, consumed candesartan 1x16mg and amlodipin
1x10mg
• He was also diagnosed with stage 5 CKD and routinely did hemodialysis twice a week every Tuesday and
Friday with double lumen access. The last time his hemodialysis was on Thusrday, September 2nd 2021 when
he admitted at Ward 17
• He was also diagnosed having HIV infection since 12 years ago but he had poor compliance on antiretroviral
therapy (he ever got 3 medication but forgot the name)
 Summary of Database
Past Medical History:
• HT (+), routinely consumed candesartan 1x16mg and amlodipin 1x10mg
• CKD stage 5 (+) routinelye hemodialysis twice a week
• HIV infection (+) had poor compliance to antiretroviral therapy

Family History:
He denied any history of HT or HIV in his family

Social History:
He denied any history of intravenous drug used, multiple sexual partner or tatto.

Review of System:
Decrease of body weight 20 kg in 1 year
 Physical Examination
General appearance Looked severely Ill Sat O2 99%on O2 10lpm NRBM
GCS 323 BW 48kg; BH 1680cm, BMI 17.6 kg/m2 (underweight)
BP 110/75 mmHg PR 118 bpm RR 24 tpm Tax 37.1oC
Head Anemic (+), oral thrush (-)
Neck JVP R+ 2cmH20, meningeal sign (-)
Chest Symmetric
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : - | -
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-| - - |-
Cardio Ictus was palpable at LMC(S) 2 cm lateral ICS V 2 cm lateral
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-)
Abdomen Soepl, Bowel Sound (+) normal, LS 10cm
Lien/ Traube dullness.
Extremity Warm (+), CRT <2s
UOP 50-100 cc/24 hours
Neurological Status Within normal limit
 Laboratory Findings (05/09/21)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 13.110 4.700 – 11.300 /µL Ureum 241,2 20-40 mg/dL

Hemoglobine 10,20 11,4 - 15,1 g/dl Creatinine 18,30 <1,2 mg/dL

PCV 29,60% 38 - 42% EGFR 2,689

Thrombocyte 87.000 142.000 – 424.000 /µL Natrium 133 136-145 mmol/L

MCV 81,80 80-93 fl Kalium 6,36 3,5-5,0 mmol/L

MCH 28,20 27-31 pg Chloride 108 98-106 mmol/L

Eo/Bas/Neu/ 0,0/0,1/85,2/3, 0-4/0-1/51-67/ PPT 11 9,4-11,3 second

Limf/Mon 7/11,0 25-33/2-5
APTT 36,40 24,6-30,6 second
SGOT 100 0-40 U/L INR 1,06 <1,5

SGPT 42 0-41 U/L D-Dimer 8,96 <0,5 mg/L

Albumin 3,52 3,5-5,5 g/dL Fibrinogen 454,7 154,3-397,9

RBG 139 <200 mg/dL HbsAg NR NR

Swab antigen Negative Negative Anti HCV Reactive NR

Blood Gas Analysis (05/09/21)
LAB VALUE NORMAL

pH 7,44 7,35-7,45

pCO2 20,9 35-45 mmHg

pO2 121,6 80-100 mmHg

HCO3 14,3 21-28 mmol/L

BE -10,1 -3 sd +3

SpO2 97,8% > 95%

Conclusion: metabolic acidosis fully compensated

Electrocardiography (05/09/21)
 Electrocardiography (05/09/21)

• Sinus tachycardia, HR 124 bpm

• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0.04 “
• PR interval : 0.13 “
• QRS complex : 0.10 “,
• ST segment : isoelectric
• QT interval : 0.42 sec
• T wave : Normal

Conclusion : sinus tachycardia, 107 bpm

Chest X-Ray (05/09/21)
 Chest X-Ray (05/09/21)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm: Dome shaped
• Phrenico-costalis angle: sharp
• Pulmo: Bronchovesicular pattern normal, infiltrate (-)
• Cor: site N, size CTR 62%, cardiac waist (-)
• Double lumen attached through V. subclavia dextra with distal
tip at VT8 projection of atrium dextra
Conclusion:
- Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. DOC 1.1 Septic IgG + Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
encephalopathy IgM - Bedrest - S, VS, GCS
1.2 Uremic Toxop - O2 10-15 lpm NRBM
Subjective
- Decrease of consciousness encepalopathy lasma - Fluid diet 6x200cc Ped
1.3 Hypoxic - Education
gradually, worsened since encepalopathhy IgG + Pharmacology about disease
1 day
- Fever (+) 3 days, diarrhea 1.4 IgM - IVFD NS 1000cc/24h progression,
Toxoplasmosis CMV - IV Ciprofloxacin diagnostic,
3 days cerebri 2x200mg treatment,
- History of CKD routinely
1.5 CMV Head - IV Metronidazol and prognosis
HD twice a week
Encephalitis CT 3x500mg
Scan - HD cito with
Objective indication of uremic
GCS 322; BP 110/75 mmHg; syndrome (uremic
HR 118 bpm, RR 24, SpO2 99%
on NRBM 10 lpm encephalopathy)
Underweight (+)
Anemic (+)
SOFA score 10
ISTH score 5 (overt DIC)
UOP 50-100cc/24 hours
Meningeal sign (-),
neurological status : within
normal limit
Lab:
Hb : 10,20
WBC: 13.110
Ur/Cr: 241.2/18.30
Kalium 6,36
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Septic 2.1 Acute UL Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
condition inflammatory FL - Bedrest - S, VS, GCS,
diarrhea Blood - O2 10-15 lpm NRBM SOFA
Subjective
- Decrease of consciousness 2.2 Complicated culture - Fluid diet 6x200cc
UTI and drug Ped
gradually, worsened since sensitivity Pharmacology - Education
1 day
- Fever (+) 3 days, diarrhea test - IVFD NS 1000cc/24h about disease
- IV Ciprofloxacin progression,
3 days 2x200mg diagnostic,
- History of HIV, poor
- IV Metronidazol treatment,
compliance of ARV
3x500mg and prognosis
Objective
GCS 322; BP 110/75 mmHg;
HR 118 bpm, RR 24, SpO2 99%
on NRBM 10 lpm
Underweight (+)
SOFA score 10

Lab:
WBC: 13,110
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. CKD stage 3.1 HTN Ca, Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
5 on HD 3.2 GNC phospor - Bedrest - S, VS, uremic
3.3 HIVAN - O2 10-15 lpm NRBM signs
Subjective - Fluid diet 6x200cc - UOP, ur, cr
- Diagnosed CKD stage 5,
routine HD in RSSA, twice Pharmacology Ped
a week. - HD cito with - Education
indication of uremic about disease
Objective syndrome (uremic progression,
GCS 323; BP 105/64 mmHg;
encephalopathy) diagnostic,
HR 112 bpm treatment,
Anemic (+)
and prognosis
Objective
GCS 322; BP 110/75 mmHg;
HR 118 bpm, RR 24, SpO2 99%
on NRBM 10 lpm
Anemic (+)
UOP 50-100cc/24 hours

Lab:
Hb : 10,20
Ur/Cr: 241.2/18.30
Kalium 6,36
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. Acute 4.1 Shigellosis FL Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
inflammatory 4.2 - Bedrest - S, VS,
diarhhea Criptosporodiasis - O2 10-15 lpm NRBM dehydration
Subjective
- Fever (+) 3 days, 4.3 MAC - Fluid diet 6x200cc signs
infection
diarrhea 3 days Pharmacology Ped
- IV Metronidazol - Education
Objective
3x500mg about disease
GCS 322; BP 110/75 - PO attapulgite 2 tab progression,
mmHg; HR 118 bpm, RR
per diarrhea, max 10 diagnostic,
24, SpO2 99% on NRBM
10 lpm tab per day treatment,
- PO zonk 1x20 mg and prognosis
- PO paracetamol
Lab: 3x500 mg prn
WBC 13,110
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
5. Anemia NN 5.1 Chronic SI, TIBC, Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
disease sat - Bedrest - S, VS
5.2 Related to transferin - O2 10-15 lpm NRBM
Subjective
- Diagnosed CKD stage renal - Fluid diet 6x200cc Ped
5.3 Bone marrow - Education
5, routine HD in suppression dt Pharmacology about disease
RSSA, twice a week.
HIV - Plan to EPO progression,
diagnostic,
Objective treatment,
GCS 323; BP 105/64
and prognosis
mmHg; HR 112 bpm
Anemic (+)

Objective
GCS 322; BP 110/75
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
10 lpm
Anemic (+)
UOP 50-100cc/24 hours

Lab:
Hb : 10,20
MCV/MCH 81.80/28.20
Ur/Cr: 241.2/18.30
Kalium 6,36
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
6. Moderate 6.1 Decreased Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
hyperkalemia renal excretion - Bedrest - S, VS, SE post
- O2 10-15 lpm NRBM correction
Subjective - Fluid diet 6x200cc
- Diagnosed CKD stage
Ped
5, routine HD in Pharmacology - Education
RSSA, twice a week. - Hyperkalemia about disease
correction 3 cycles: progression,
Objective ca glukonas 10mg + diagnostic,
GCS 323; BP 105/64
D40% 50cc + insulin treatment,
mmHg; HR 112 bpm
Anemic (+) 10IU and prognosis
- HD
Objective
GCS 322; BP 110/75
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
10 lpm
Anemic (+)
UOP 50-100cc/24 hours

Lab:
Hb : 10,20
Ur/Cr: 241.2/18.30
Kalium 6,36
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
7. 7.1 Septic DIC Treat underlying disease PMo
Mrs. A/ 45 yo/ward 26
Thrombocyto (infection) - S, VS, ISTH
penia + 7.2. Bone score.
Subjective
- Decrease of Increased D marrow
dimer suppression dt Ped
consciousness HIV - Education
gradually, worsened
since 1 day about disease
- Fever (+) 3 days, progression,
diagnostic,
diarrhea 3 days
treatment,
Objective and prognosis
GCS 322; BP 110/75
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
10 lpm
Underweight (+)
SOFA score 10
ISTH score 5 (overt DIC)

Lab:
Trombocyte 87.000
D dimer 8,96
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
8. Chronic hepatitis HCV RNA, Waiting HCV RNA result PMo
Mrs. A/ 45 yo/ward 26
C infection fibroscan - S, VS, LFT
Objective
Ped
GCS 322; BP 110/75 - Education
mmHg; HR 118 bpm, RR about disease
24, SpO2 99% on NRBM
10 lpm progression,
diagnostic,
treatment,
Lab:
and prognosis
Anti HCV reactive
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
9. HF stage C 9.1 HHD Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
Fc II 9.2 CRS type IV - Bedrest - S, VS
- O2 10-15 lpm NRBM
Subjective - Fluid diet 6x200cc Ped
• History of HT routinely - Education
consumed candesartan Pharmacology about disease
1x16 mg and amlodipin - Ramipril 0-0-2,5 mg
1x10 mg progression,
 postponed until diagnostic,
hyperkalemia treatment,
Objective
resolved and prognosis
GCS 322; BP 110/75
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
10 lpm
Ictus palpable at 2 cm
lateral ICS V, MCL Sinistra

CXR:
Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
10. HT on Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26
treatment - Bedrest - S, VS
- O2 10-15 lpm NRBM
Subjective - Fluid diet 6x200cc Ped
• History of HT routinely - Education
consumed candesartan Pharmacology about disease
1x16 mg and amlodipin - Amlodipin10 mg-0-0
1x10 mg progression,
diagnostic,
treatment,
Objective
and prognosis
GCS 322; BP 110/75
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
10 lpm
Ictus palpable at 2 cm
lateral ICS V, MCL Sinistra

CXR:
Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
11. HIV st III - Non-Pharmacology PMo
Mrs. A/ 45 yo/ward 26 - Bedrest - S, VS, CD4
- O2 10-15 lpm NRBM - Find
Subjective - Fluid diet 6x200cc opportunistic
Diagnosed HIV but had
infection : IgG
poor compliance of Pharmacology IgM
antiretroviral therapy - Consult to tropmed Toxoplasma +
division for IgG IgM CMV
Objective antiretroviral + TPHA +
GCS 322; BP 110/75
therapy VDRL
mmHg; HR 118 bpm, RR
24, SpO2 99% on NRBM
Ped
10 lpm - Education
Underweight about disease
progression,
diagnostic,
treatment,
and prognosis
 PROBLEM ANALISYS

Hypertension HIV

Anemia

CKD Immunocompromised

hyperkalemia Diarrhea Septic

Uremic

DOC
 Risk factors: CKD
Type Definition
Susceptibility factors Factors that increase
susceptibility to kidney damage
Initiation factors Factors that directly initiate
kidney damage
Progression factors Factors that cause worsening
kidney damage and faster
decline in kidney function after
kidney damage has started
End-stage factors Factors that increase morbidity
and mortality in kidney failure
Example
Older age, family history of chronic kidney
disease, reduction in kidney mass, low birth
weight, U.S. racial or ethnic minority status, low
income or educational level.
Diabetes mellitus, high blood pressure,
autoimmune diseases, systemic infections,
urinary tract infections, urinary stones,
obstruction of lower urinary tract, drug toxicity
Higher level of proteinuria, higher blood
pressure level, poor glycemic control in diabetes,
smoking
Lower dialysis dose, temporary vascular access,
anemia, low serum albumin level, late referral
for dialysis
 Features: CKD
Clinical manifestations

Underlying diseases Uremic syndrome Complications

Anemia, HT, renal osteodystrophy,

DM, UTI, Urolithiasis, metabolic acidosis, electrolite
HT, hyperuricemia, SLE imbalance

Weakness, letargy, anorexia, nausea

& vomiting, nocturia, volume
overload, Pheripheral neuropathy,
pericarditis, seizure.
 Managements: Hypertension
Hypertension

Renovascular
Non - Diabetes mellitus Diabetes mellitus
hypertension

Proteinuric Non-proteinuric
(urine albumin/creatinine (urine albumin/creatinine
≥ 30 mg/mmol) < 30 mg/mmol)

ACE inhibitors or ARB if Either: ACE inhibitors,

intolerance to ACE ARB, thiazid diuretics, or
inhibitors β-blockers
 Managements: Anemia

Anemia

Adequate iron stores

Erythropoiesis-stimulating
Iron
agents

Target
Target Hb > 11 gr/dl 1. Ferritin > 100 ng/mL
2. Transferrin saturation > 20%
 Managements: RRT

eGFR < 20 with

1. Symptoms of uremia (after excluding other causes)
2. Refractory metabolic complications (hyperkalemia, acidosis)
3. Volume overload (manifesting as resistant edema or hypertension)
4. Decline in nutritional status (as measured by serum albumin, lean
body mass or Subjective Global Assessment)
 Prognosis

• Ad vitam : Dubia
• Ad functionam : Dubia
• Ad sanationam : Dubia
 Condition this morning

• GCS : 322
• TD: 106/62 mmHg
• HR: 118bpm
• RR: 24 tpm
• T: 36.8C
• Spo2: 98% on O2 10lpm NRBM