MORNING REPORT

Date : July 26, 2018

Physician in charge
I : dr. Jefri, dr. Dipto, dr. Arum, dr. Anita (cardio)
II CVCU : dr. Adys
II HCU : dr. Roni
II UGD : dr. Rima
Chief on duty : dr. Ricky
Consultant on duty : dr. Supriono, SpPD-KGEH
Facilitator : dr. Rulli Rosandi, SpPD-KEMD
 Summary of Database
Mr. AM/37 yo/ward 25 bed 2.3
Chief Complaint:
shortness of breath
History of Present Illness:
patient with shortness of breath since 3 days ago and got worse since this afternoon. The
SOB got worse when he was hemodialyzed, but got better after that. He said that whenever
he walked more than 100 metres, he felt SOB. He sleeps with 2 pillows every night since got
diagnosed with CKD 3 years ago. Routinely HD twice a week, every wednesday and saturday.
He took micardis 80 mg once daily, clonidin 3x0,15 mg, amlodipin 10 mg once dailt, and
furosemide 3x40 mg every day, but he rarely took the furosemide. He also felt nausea and
vomiting since these 3 days, vomiting about 1-2 times a day, contains of food and water.
 Summary of Database
Past Medical History:
hypertension since 3 years ago, took medicine routinely
Family History:
no history of HT in his family
Social History:
he is a freelancer
Review of System:
fever (-)
 Physical Examination
General appearance look moderately ill Sat O298% room air
GCS 456 compos mentis VAS 0/10
BP 190/120 mmHg PR 112 bpm regular strong RR 23 tpm Tax 36,3 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+3 cmH20
Chest Symmetrical, retraction (-)
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 , Pathologic Reflex (-); Lateralization (-)
5|5
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. AM.37 yo/ward 25 bed 2.3 1. SOB 1.1 Cardiogenic Echocardiogr •O2 8-10 Lpm via NRBM Subjective
1.1.1 Accelerated HT aphy •Bed rest BP
Subjective 1.1.2 HF st C fc IV •Semifowler position HR
SOB 3 days NT pro BNP • Drip furosemide 20 RR
Relieved in sitting position 1.2. Non Cardiogenic mg/hour (insert 10 amp Urine
DOE (+) 1.2.1 uremic lung furosemide @20mg in 100 production
Hypertension since 3 years cc NaCl 0.9% - 10cc/hour) ECG
Routine HD since 3 years ER
• inj, Furosemide 3x40 mg Pedu :
Objectives IV (ward) - Fluid
BP: 190/120 • Negative fluid balance - restrictio
HR: 112 bpm, reguler 500cc to -1000cc/24hours n
RR: 23 - Semifow
Anemia conjungtiva (+/+) po: ler
Cor : ictus ICS V1 2 cm lateral clonidin 3x0,15 mg position
MCL S micardis 1x80 mg - Always
Pulmo : Rhonchi medial and amlodipin 1x10 mg use the
basal lung D, decreased breath mask of
sound and ronchi at bilateral oxygen
basal lung
Leg edema -/-

ECG: sinus tachycardia 120 bpm

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

Mr. AM.37 yo/ward 25 bed 2.3 2. CKD Stage 5 on 2.1 HT Nephrosclerosis renal biopsy • O2 NC 2-4 lpm BP, HR, RR
rutine HD 2.2 DKD • Bedrest SaO2,
Subjective • Renal Diet 1700 kkal/hr, low
-CKD since 3 years ago salt < 2 gr/day, protein 1
-HT known since 3 years ago gr/kgBB/day Pedu
-routinely HD Educate the
• elective HD patient about
Objective the cause of
BP: 190/120 CKD .
HR: 112 bpm, reguler
RR: 23
anemic (+)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. AM.37 yo/ward 25 bed 2.3 3. HT urgency 3.1 secondary funduscopy -renal diet 1700 kcal/day, low BP, HR, RR
3.2 primary salt diet
Subjective Pedu
-hypertension known since 3 po clonidin 3x0,15 mg Educate the
years ago po amlodipin 1x10 mg patient about
-routinely took colnidin, micardis, po micardis 1x8 mg the diet
amlodipin

Objective
BP: 190/120
HR: 112 bpm, reguler
RR: 23

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

Mr. AM.37 yo/ward 25 bed 2.3 4. HF Stage C fc 4.1 Uremic Echocardiogr • O2 NC 2-4 lpm BP, HR, RR
III Cardiomyopathy aphy • Bedrest SaO2,
Subjective • Renal Diet 1700 kkal/hr, low
-SOB (+) salt < 2 gr/day, protein 0.6- Pedu
-DOE (+) 0.8 gr/kgBB/day Educate the
-PND (+) patient about
-HT on treatment • po: furosemide 3x40 mg the cause of
HF and
Objective management
BP: 190/120
HR: 112 bpm, reguler
RR: 23
ictus visible, palpale at 2 cm
lateral MCL V sinistra

CXR: cardiomegaly
 Problem Analysis

History of poorly
uncontrolled HF
hypertension

CKD st 5
Hypertension
urgency Uremic
lung

ALO
RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL

CKD st V Risk Factor of CKD that Hypertension

undergone HD
Glomerulonefritis
Diabetes Melitus
Obstruction and infection
Hypertension
Other Causes

PAPDI
 RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL

Heart Faillure - CKD - CKD

- Hypertension - Hypertension
- Overload - Overload
- Anemia
- Lung problems
RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL

Hypertension Increased age Increased age

Family history
Race black
Family history
Overweight/Obese
Not physically active
Using tobacco
Sodium diet
Little potassium diet
Little vitamin D
Alcohol
 Management Analysis
Problem Theory Factual
Chronic Haemodyalisis
Kidney
Disease Treatment of Chronic Kidney Disease
Based on Stages (PAPDI)
Stages GFR Treatment
1 ≥90 Treat undelying disease, comorbid condition,
evaluation of worsening renal function, reduced
cardiovascular risks.
2 60-89 Menghambat perburukan fungsi ginjal
3 30-59 Evaluasi dan terapi komplikasi
4 15-29 Persiapan untuk terapi pengganti ginjal
5 ≤15 Terapi pengganti ginjal

• Specific treatment for underlying disease

• Prevent and treatment of comorbid condition
• Slow down the disease progression
• Prevent and treatment for cardiovascular diseases
• Renal replacement therapy including dialysis and
renal transplantation
 MANAGEMENT ANALYSIS
Heart Failure Management of Heart Failure
- Restriction of activity
- Dietery sodium restriction
2-3 gram/ day
- Diuretics
- ACEIs, ARB
- Hydralazine and Nitrat
- Digoxin
- Anticoagulants
- Inotropic agents
•O2 8-10 Lpm via NRBM
•Bed rest
•Semifowler position
• Drip furosemide 20 mg/hour
(insert 10 amp furosemide
@20mg in 100 cc NaCl 0.9%
- 10cc/hour) ER
• inj. Furosemide 3x40 mg IV
ward
• Negative fluid balance -500cc
to -1000cc/24hours
 MANAGEMENT ANALYSIS
Theory Factual
Hypertension Life Style Modification Life Style Modification
Stage 1
Thyazide-type diuretics for most. May
consider ACEI, ARB, BB, CCB or Clonidine tablet 3x0.15 mg
combination
Stage 2 Amlodipin tablet 1x10 mg
Two drugs combination for most Telmisartan 1x80 mg
(usually thyazide-type diuretics and
ACEI or ARB or BB or CCB)

JNC 7
Condition this morning
• GCS 4-5-6
• BP : 170/100 mmHg
• PR : 92 bpm
• RR : 22 tpm
• Tax : 36,1
• UOP : 100 cc / hour