dr.

Firdha
MORNING REPORT

Date : Monday, 8th March 2021

Physician in charge
I : dr. Nanda, dr. Adsanu, dr. Puput
II Consultant : dr. Firman
HCU : dr. Dandi
Incovit : dr. Jonny
UGD : dr. Firdha, dr. Caesar
Chief on duty : dr. Dinda
Consultant on duty : dr. M. Ansory, SpPD
RESUME
Admission Discharge MedCon Pass away Remaining Total

2 0 1 0 0 2

Resume

Admission Discharge MedCon Pass away

 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning Ward
Initial Diagnosis

P2 Reguler ER/ Mr. BT/ 61 yo Emergency Planning Diagnosis: ER

PRIMARY SURVEY: Airway; Patent, Breathing: Spontaneous, (-) Sputum culture + AB sensitivity
Circulation: Warm FBG, 2hPPBG
History Taking: Chief complain: Shortness of Breath Urgency
- Shortness of Breath since 4 days ago, didn’t affect by activity. Cough (-) Planning therapy :
(+) sometimes Non pharmacologic
- Fever since 3 days ago Non-Urgency - Bed rest
- Pain at right knee since 4 days ago, worsening when doing activity 1. Pneumonia CAP PSI 71 Risk - O2 NC 2-4 lpm kp
and relieve when resting, stiffness (-), swollen (+). History of trauma Class III - Soft Diet High Calory High Protein
(-), history of knee pain before (+) 6 months ago 2. Pancytopenia due to Aplastic Decrease of BW with minimal 5% BW, target BMI
- Has diagnosed Aplastic Anemia since 1 month ago, and history of Anemia 18.5-25%
recurrent transfusion 3. Osteoarthritis Tibiofemoral
- Epistaxis, Gum bleeding, Black tarry stool and another bleeding was et Patellofemoral Genu Dextra Pharmacologic
denied 4. Hyperglycemia State - Rehydration NS 500cc  continued maintenance
- History medication from previous hospital: Pantoprazole,      4.1 Steroid Induced IVFD NS 1500cc/24 hours
Tranexamic Acid, Methylprednisolone, Ceftriaxone, Levofloxacin,      4.2 DM type 2 - IV Levofloxacin 1x750 mg (D-4) continued from
Furosemide, Vit B, folic acid, Paracetamol 5. Mild Hypoalbuminemia previous hospital
5.1 Hypercatabolic state - PO Paracetamol 3x500 mg
Objective : GA Looked Moderately Ill, GCS 456, BP 137/84 mmHg, N 6. Obesity Grade 1 - PO Folic Acid 1x3 mg
66x/m, RR 26x/m, Tax 39.1°C, SaO2 98% RA, VAS 3/10 regio Genu D; - PO Vit B12 3x50 mcg
BMI 31.0 kg/m2 - Transfusion TC 1 unit/10 kgBW until PLT >
Positive findings: H/N anemic conjungtiva (+), Thorax: rh -|-, wh -|-, 20,000
Ext: ptechie (+) - Consult to Rehab Medic for Physic therapy
Localized status Genu D; L: Odem (+), F: calor (+), M: ROM normal, UpToDate, 2021 (muscle strengthening)
tenderness (-), crepitation (-), patelar tap test (-) IRA, 2014
Planning Monitoring:
Lab : CBC 9,20/880/24,90%/10.000; MCV/MCH 76,60/28,30; Diff S, VS, SpO2, VAS, Bleeding sign, RBS, albumin
count 0,0/0,0/19,3/71,3/9,1%; NLR 0,27; TLC 630; ANC 170; SE
134/3,48/96; PPT 11,40 (11,0), APTT 21,10 (25,8), INR 1,10; RBS 209; Planning Education
Ur/cr 41,3/0,83; SGOT/PT 24/22; Albumin 3,01; Bil T/D/I Educate to patient and his family about current
0,39/0,28/0,11; CRP 4,63; Procalcitonin 0,09; Eclia NR; BGA pH condition and diagnose. discussion about planning
7,50/PCO2 42,0/PO2 141,4/HCO3 33,0/BE 9,6/SaO2 97%; Lactic Acid diagnosis, therapy and monitoring. Give
physichosocial support.
3,2

BMP 10/02/2021: Aplastic Anemia with Benign Plasmacytosis

Swab PCR SARS-CoV-2 (5-6/3/2021) Negative
CXR: Infiltrate at paracardial Dextra suspect Pneumonia
Genu D AP/Lat: OA tibiofemoral joint D gr II, OA patellofemoral joint
D
ECG: Sinus tachycardia, HR 101 bpm