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Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT
October 12nd 2014
TEAM 3

Mr. M (56 yo)


Findings

Assessment

CC : breathless, cough, nausea


Appearance: moderate illness, GCS : E4V5M6, BP: 150/70
mmHg, PR : 101 x/min (adequate,regullar) RR : 30 x/min,
T: 36 C
Eye : conjuntiva not pale, Sklera icteric -/Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention +
THORAX
Insp : symmetric, ictus cordis (-)
Pal : vf symmetric, ictus cordis palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : bronchial rh -/-,wh-/S1 single, S2 single, regular, murmur (-) gallop (-)
ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 4x
Palp : Pressure Pain Undulation(-),
Per : timpany, shifting dulness (-),
BACK:
Per : CVA (+)
- Extremitas : warm acral, CR<2, edema

LAB FINDING:
Complete Perifer Blood :
Hb : 7,2 gr/dl Leu : 15.800/ul ; Ht : 20,6%
Tro : 336.000/ul, ureum: 197, creatinine : 13,17

CKD grade V with


overload
Anemia

Therapy
Pro Hospitelize
IVFD : Inj plug
Diit : smooth with 40gr
protein
Mm/
Bicnat 3x1
Ceftriaxon 1x2 gram
CaCo3 3x1
Furosemide 2x1amp
Ranitidine 2x1amp
Pro Renal 3x2
Check balance

Planning

Check balance
Check blood gas
analysis and electrolite

Subjective Data
Name
Address
TC
CC

: Mr. M
: Jakarta
: Sunday/12nd October 2014
: Breathless

Anamnesis
Main symptom
Additional symptom

: Breathless
: Cough, nausea

56 years old male patient came to hospital with complaint of breathless since
three days before admission. The complaint came suddenly and continously. The pain
wasnt diffuse to arm and spine. Pain felt worsen while lying down, and better when
sitting. The other complaints he had were cough and nausea (since 3 days before
admission).
Patient has no history of hypertension, diabetes mellitus. The patient denied
any cough. The patient denied any complaints on the urination and defecation but
the patient consume medication for kidney since 4 years ago. The patient denied
history of allergy.

Past Medical History and Treatment


the patient consume medication for kidney since 4 years ago.
Family History
(denied)
Social History
Smoke (-) since 4 years ago, Alcohol (-), Drug induced (-),

Objective Data
LOC
Appearance
BP
PR
RR
Temp
EYE
Neck

: E4V5M6 ; Composmentis
: moderate ill
: 150/70 mmHg
: 101 x/min (adequate,regular)
: 30 x/min
: 360C
: anemic conjungtiva -/- ; ict -/: lymph nodes did not enlarged, venous distention +

THORAX
:
Heart
Ins : IC not visible
Pal : IC palpable
Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO
Insp
Pal
Perc
Ausc
ABDOMEN
Insp
Ausc
Pal
Perc
BACK
Perc

: Static and dynamic symmetric


: VF right and left symmetric
: Sonor symmetric
: BBS Brochial, Rhonci -/-, Wheezing -/: Stomach looks flat
: Bowel sound (+)
: undulation (-)
: shifting dulnes (-)
: CVA (+)

EXTREMITIES
Edema (-); warm (+); capp. Refill <2 seconds

Clinical Laboratory

Hb
Ht
Leukosit
Trombosit
Ureum
Creatinin

: 7,2 gr/dl
: 20,6%
: 15.800/ul
: 336.000/ul
: 197
: 13,17

Assessment

CKD stage V with overload


Anemia

Therapy
Pro Hospitalized
IVFD : Inj. plug
Diit : Smooth, 4gr protein
Mm/
- Furosemide 2x1amp
- Ceftriaxon 1x2gr
- Ranitidine 2x1amp
- CaCo3 3x1
- Pro Renal 3x2 tab
- Bicnat 3x1 tab

Planning
Check balance
Check blood gas analysis and electrolite

Department of Internal Medicine


Christian University of Indonesia

Thank You