MORNING REPORT

Monday, May 30th 2017

Coass in charge
Hasan
Muhammad Firas Balafif
Monica Sari Devy
Amelia Fitra
Sari Mufliha
Ilham Choiriyah

Spv: dr. Atma Gunawan Sp.PD K.GH

 Anamnesis
Identity : Mr. AM/69 yo/ward 26
Heteroanamnesis
Chief complain: decrease of consciousness
History of present illness:
The patient was admitted to the ER due to decrease of
consciousness since 2 day before admission gradually. Initially, he was hard to
communicate. Then at the ER, he couldnt communicate clearly. he also suffered form
shortness of breath since 1 day before admission. he never wakes up at night due to
shortness of breath.
He also suffered from leg swelling since 5 days ago. He felt heavier
when standing or walking. He complained that he had decreased frequency and volume
when passing urine since 2 months ago. The patient didnt know exactly how much his
urine volume production
He also suffered from nausea without vomiting since 1 month ago.
He drinks hot/warm water to relieve the nausea. He eats 3 times a day but only ate 2
spoons each meal. He only wants to eat porridge.
Patient had general weakness since 1 week before admission,
general weakness is felt continuously, patient still didnt daily activity. general weakness is
felt gradually. His family said that he looked pale.
 Anamnesis
Patient had diagnosed with hypertension since 1 years ago, Her his highest blood
pressure was 200 /.. He didnt routinely controlled nor took any medication

Past medical history :

He was diagnosed HT 1 year ago and he never got any treatment.
Family history :
History of DM (-), chronic kidney disease (-).
Allergy history: (-)
Social history :
He wasnt married and had 4 siblings.
Every day he cant wear clothes and take a bath by himself.
History of smoking (-). Alcohol consumption (-).
 Physical Examination
General appearance : looked severe ill GG
GCS : 224 211 CS 224 looked normoweight
BP : HR 116 bpm RR : 24 tpm Tax : 37.1 0C
180/80mmHg120 regular76bpm
/70mmhg
Head Anemic conjunctiva (+), icteric sclera (-),gaze conjugaete (-)S

Neck JVP R+2 cm H2O at 300, lymph node enlargement (-)

Thorax : Cor Ictus unvisible and palpable at ICS V 1 cm lateral MCL sinistra
LHM ~ ictus RHM: SL D
S1, S2 normal, gallop (-), murmur (-)
Pulmo Symmetric , Percussion sonor sonor Rh - - wheezing - -
sonor sonor - - --
sonor sonor -- --
Abdomen flat, soefl, bowel sound (+) normal, liver span 8 cm, traubes space was
tympanic, epigastric pain (-)
Extremities Warm acral Lateralisation (-)
edema extremities +/+
+/+
 Laboratory Findings
Laboratory 28/5/17 Normal Value Laboratory 28/5/17 Normal
Value
Hb 6.70 11.4 15.1 Natrium 138 136 145
g/dL mmol/L
Leucocyte 15.620 4,300- Kalium 7.44-> 3,5 5,0
10,300/L 6.75 mmol/L
Hematocrit 20.40 40 47 % Chloride 121 98 106
mmol/L
PLT 389000 142.000- Ureum 431.30 16.6-48.5
424.000/L mg/dl
Eo/Bas/Neu 0.1/0.1/9 0-4/0-1/51- Creatinin 13.78 <1.2
/Lym/Mono 1.5/2.0/0 67/25-33/2-5 eGFR 3.8 mg/dL
.3 % BUN mL/min/1,7
3m2
MCV 72.10 80 93 fl SGOT 11 0-32
MCH 23.70 27 31 pg SGPT 15 0-33
60-100 mg/dL
Blood Gas Analysis (28/5/2017)
Parameter Patient Value Adult Normal
Value
PH 7.13 7.35-7.45
PCO2 15.3 35 - 45
PO2 192.0 80 100
HCO3 5.1 21 28
O2 sat Art 95.9 > 95 %
BE -24.4 (-3) - (+3)
Temp 37.0
Conclusion :Asidosis metabolic partially compensated
with alkalosis respiratorik
 Urinalysis
Date : 27/5/2017

Parameter Value Lab Value

PH 5.5 10 x
SG 1.015 Epithelia 0.1
Glucose Negative Cylinder Negative
Protein +2 Hyaline Negative
Keton Negative Granular Negative
Bilirubin Negative 40 x
Urobilinogen Negative Erythrocyte 35.6
Eumorphic 87%
Dismorphic 13%
Nitrite Negative Leukocyte 25.1 LPB
Leucocyte +3 Crystal Negative
Blood +3 Bacteria 1239.7 x 103
Chest X-
Ray
27 Mei 2017
 Chest X-Ray
Date : 27 Mei 2017

AP position, asymmetric, enough KV, enough inspiration

Soft tissue normal, Bone normal
Trachea in the middle
Hemi diaphragm D and S were dome shape
Phrenic costal angle D and S were sharp
Lung : There is no infiltrate
Heart : site normal, size CTR 58%, shape normal

Conclusion : Cardiomegaly
ECG
 ECG (28 May 2017)

Sinus rhytm ,Heart rate 81 bpm

Frontal Axis : normal
Horizontal Axis : normal
PR interval : 0.20
QRS complex : 0.08
QT interval : 0.38
Conclusion : sinus rhytm with heart rate 81 bpm
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 1. DOC 1.1 Uremic Blood&Uri Bed rest P.Mo: S,
History enceph ne O2 15 lpm NRBM ur, cr, SE
DOC 2 day before alopat (Culture
admission Insert NGT and post HD
hy +Sensitivit
Gradually onset cathether
Newly Diagnosed with 1.2 Septic y test)
Fluid diet 6 x 200 cc
P. Edu:
CKD 1 day ago enceph
alopat Haemo
Physical Examination
GCS 224211 hy Haemodyalised cito dyalised
BP : (Has already done) routinel
180/80mmHg120/70m y
mHg
RR : 24 tpm
HR :11676bpm
Conjunctiva anemis (+)
Dry skin
Leg and arm edema (+/+)
Lab
Hb 6,7 g/dL
Ur 431 mg/dL
Cr 13,78 mg/dL
eGFR 3.8 mL/min/1,73m2
BUN/Cr 14.61
WBC 15.620/L
Urinalisa :
Leucosite : 25.1/hpf
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 2.CKD St 2.1Hyperte Abdominal Bed rest P.Mo: S,
History 5 newly nsion USG ur, cr, SE
DOC 2 day before semifowler
admission
diagnos nefroscl O2 15 lpm NRBM post HD
Gradually onset e erotic
Inserted NGT and
Newly Diagnosed with CKD 2.2 GNC P. Edu:
1 day ago catheter
Haemod
Nausea and without Fluid Diet 6 x yalised
vomiting since 1 month ago 200cc, protein 0.8
Physical Examination
routinely
GCS 224 g/KgBW/day
GCS 224211 Injection
BP : 180/80mmHg furosemide 3x40
120/70mmHg
RR : 24 tpm mg iv
HR :11676bpm Per NGT :
Conjunctiva anemis (+) CaCO3 3x500mg
Leg and arm edema (+/+)
Dry skin
Lab Haemodyalised cito
Hb 6,7 g/dL
MCV 72.1 fL
(Has already done)
MCH 23.0 pg
Ur 431 mg/dL
Cr 13,78 mg/dL
eGFR 3.8 mL/min/1,73m2
BUN/Cr 14.61
WBC 15.620/L
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Mr. M/69 YO/W.26 3. 3.1 funduscopy Renal diet 1,700 Subjecti
AX: Hiperten Primary kcal/day, Low v,BP
History of Hipertension
since 1 year ago & didnt sion hypertens sodium salt Diet <
take medication. St.II ion 2gr/day,
3.2 Amlodipine 1x10mg PEd :
Low sodium
PE:
secondar salt Diet

BP : 180/80 mmHg y
hypertens
ion
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 4. 4.1 SI, TIBC, PRC transfussion P. Mo:
History Anemia Relativ Ferritin 250cc durante HD Hb after
Fatigue and hipocro e to life (Has already done) transfuss
weakness me & span Plan to EPO (waiting ion
microsite RBC for lab result)
PE: r 4.2 chronic P.Edu:
Anemia conjungtiva disease Disease
4.3 and
Lab Deficie treatme
Hb 6.70 g/dL ncy Fe nt
MCV 72.1 fL 4.4
MCH 23.3 pg Deficie
ncy
EPO
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 5. 5.1 Endoscopy Correction P.Mo:
History Hiperkale Decrea hyperkalemia Kalium
Newly Diagnosed with mia se of - Inj Ca gluconas post
CKD 1 day ago renal correctio
1 Gram
Nausea and without excreti n
- Short acting
vomiting since 1 on
month ago 5.2 insulin 10 IU P.Edu:
Acidosi - D40% 2 flasg
Physical Examination s (3 cycle)
GCS 224 metab Per NGT
Conjunctiva anemis (+) olic -kalitake 3x 5gram
Dry skin
Leg and arm edema
(+/+)
Lab :
Ur 431 mg/dL
Cr 13,78 mg/dL
eGFR 3.8
mL/min/1,73m2
BUN/Cr 14.61
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 6. 6.1 Uremic Injection P.Mo:
History Dyspepsi gastrop omeprazole 1 x 40 nausea
Newly Diagnosed with a athy mg Intravena
CKD 1 day ago syndrom 7.2 PUD P.Edu:-
Nausea and without e
vomiting since 1
month ago

Physical Examination
GCS 224
Conjunctiva anemis (+)
Dry skin
Leg and arm edema
(+/+)
Lab :
Ur 431 mg/dL
Cr 13,78 mg/dL
eGFR 3.8
mL/min/1,73m2
BUN/Cr 14.61
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Male/69 YO 7. UTI Injection P.Mo:
History asympto Ciprofloxacin nausea
Newly Diagnosed with matic 2x200mg intravena
CKD 1 day ago P.Edu:-

Lab :
Urinalisa :
Leucosite : 25.1/hpf
 Condition This Morning

GCS : 111
BP : 110/75 mmHg
PR : 82 bpm
RR : 22 tpm
Tax: 36.5 0C

SpO2 : 97 % room air

Urine Production 50 cc/4 hours ~ 16 cc per
hour
Thank You