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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 couldn’t 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 didn’t 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.

History of smoking (-). chronic kidney disease (-). Her his highest blood pressure was 200 /…. Family history : History of DM (-). Every day he can’t wear clothes and take a bath by himself. Alcohol consumption (-). Allergy history: (-) Social history : He wasn’t married and had 4 siblings. Anamnesis Patient had diagnosed with hypertension since 1 years ago. . He didn’t routinely controlled nor took any medication Past medical history : He was diagnosed HT 1 year ago and he never got any treatment..

. bowel sound (+) normal.gaze conjugaete (-)S Neck JVP R+2 cm H2O at 300. soefl. S2 normal.wheezing .- sonor sonor . Percussion sonor sonor Rh . murmur (-) Pulmo Symmetric . -- sonor sonor -. gallop (-). lymph node enlargement (-) Thorax : Cor Ictus unvisible and palpable at ICS V 1 cm lateral MCL sinistra LHM ~ ictus RHM: SL D S1. liver span 8 cm. icteric sclera (-). Physical Examination General appearance : looked severe ill GG GCS : 224  211 CS 224 looked normoweight BP : HR 116 bpm RR : 24 tpm Tax : 37. -- Abdomen flat. traube’s space was tympanic. epigastric pain (-) Extremities Warm acral Lateralisation (-) edema extremities +/+ +/+ .1 0C 180/80mmHg120 regular76bpm /70mmhg Head Anemic conjunctiva (+)..

30 16. Kalium 7.8 mg/dL .000/µL mg/dl Eo/Bas/Neu 0.620 4.5 424. Creatinin 13.000.78 <1.2 /Lym/Mono 1.0/0 67/25-33/2-5 eGFR 3. Laboratory Findings Laboratory 28/5/17 Normal Value Laboratory 28/5/17 Normal Value Hb 6.300/µL 6.44-> 3.10 80 – 93 fl SGOT 11 0-32 MCH 23.1 Natrium 138 136 – 145 g/dL mmol/L Leucocyte 15.300.6-48.70 27 – 31 pg SGPT 15 0-33 60-100 mg/dL .70 11.7 3m2 MCV 72.0 10.4 – 15.5/2. Ureum 431.40 40 – 47 % Chloride 121 98 – 106 mmol/L PLT 389000 142.1/0.1/9 0-4/0-1/51.75 mmol/L Hematocrit 20.5 – 5.3 % BUN mL/min/1.

1 21 – 28 O2 sat Art 95.0 Conclusion :Asidosis metabolic partially compensated with alkalosis respiratorik .45 PO2 192.0 80 – 100 HCO3 5.45 PCO2 15.9 > 95 % BE -24.Blood Gas Analysis (28/5/2017) Parameter Patient Value Adult Normal Value PH 7.13 7.(+3) Temp 37.4 (-3) .3 35 .35-7.

1 Glucose Negative Cylinder Negative Protein +2 Hyaline Negative Keton Negative Granular Negative Bilirubin Negative 40 x Urobilinogen Negative Erythrocyte 35.015 Epithelia 0.6 Eumorphic 87% Dismorphic 13% Nitrite Negative Leukocyte 25.1 LPB Leucocyte +3 Crystal Negative Blood +3 Bacteria 1239.5 10 x SG 1.7 x 103 . Urinalysis Date : 27/5/2017 Parameter Value Lab Value PH 5.

Chest X- Ray 27 Mei 2017 .

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. asymmetric. shape normal Conclusion : Cardiomegaly . Chest X-Ray Date : 27 Mei 2017 • AP position. size CTR 58%.

ECG .

08” • QT interval : 0. ECG (28 May 2017) • Sinus rhytm .20” • QRS complex : 0.Heart rate 81 bpm • Frontal Axis : normal • Horizontal Axis : normal • PR interval : 0.38” • Conclusion : sinus rhytm with heart rate 81 bpm .

DOC 1. Edu: CKD 1 day ago enceph alopat Haemo Physical Examination GCS 224211 hy Haemodyalised cito dyalised BP : (Has already done) routinel 180/80mmHg120/70m y mHg RR : 24 tpm HR :11676bpm Conjunctiva anemis (+) Dry skin Leg and arm edema (+/+) Lab Hb 6.73m2 BUN/Cr 14.78 mg/dL eGFR 3. cr.1 Uremic Blood&Uri Bed rest P. SE DOC 2 day before alopat (Culture admission Insert NGT and post HD hy +Sensitivit Gradually onset cathether Newly Diagnosed with 1.7 g/dL Ur 431 mg/dL Cr 13. CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 1.620/µL Urinalisa : Leucosite : 25.Mo: S. History enceph ne O2 15 lpm NRBM ur.8 mL/min/1.2 Septic y test) Fluid diet 6 x 200 cc P.61 WBC 15.1/hpf .

1 fL (Has already done) MCH 23.7 g/dL MCV 72.73m2 BUN/Cr 14. 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. Edu: 1 day ago catheter Haemod Nausea and without Fluid Diet 6 x yalised vomiting since 1 month ago 200cc. History 5 newly nsion USG ur.8 mL/min/1.0 pg Ur 431 mg/dL Cr 13. protein 0.CKD St 2.2 GNC P.78 mg/dL eGFR 3.61 WBC 15.1Hyperte Abdominal Bed rest P.8 Physical Examination routinely GCS 224 g/KgBW/day GCS 224211 Injection BP : 180/80mmHg furosemide 3x40 120/70mmHg RR : 24 tpm mg iv HR :11676bpm Per NGT : Conjunctiva anemis (+) CaCO3 3x500mg Leg and arm edema (+/+) Dry skin Lab Haemodyalised cito Hb 6. cr.620/µL .Mo: S. CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 2.

St.II ion 2gr/day. M/69 YO/W. Low v.26 3.1 funduscopy Renal diet 1.BP History of Hipertension since 1 year ago & didn’t sion hypertens sodium salt Diet < take medication. 3.700 Subjecti AX: Hiperten Primary kcal/day. CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Mr.2 Amlodipine 1x10mg PEd : Low sodium PE: secondar salt Diet BP : 180/80 mmHg y hypertens ion . 3.

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 4.1 SI.4 MCH 23. TIBC.1 fL 4. CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 4.2 chronic P.Edu: Anemia conjungtiva disease Disease 4. 4. PRC transfussion P.3 pg Deficie ncy EPO .70 g/dL ncy Fe nt MCV 72.3 and Lab Deficie treatme Hb 6.

Edu: Acidosi .8 mL/min/1.2 insulin 10 IU P.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.Inj Ca gluconas post CKD 1 day ago renal correctio 1 Gram Nausea and without excreti n .78 mg/dL eGFR 3. 5.61 .1 Endoscopy Correction P.Short acting vomiting since 1 on month ago 5.73m2 BUN/Cr 14.Mo: History Hiperkale Decrea hyperkalemia Kalium Newly Diagnosed with mia se of . CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 5.

1 Uremic Injection 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 13.2 PUD P.61 .8 mL/min/1.78 mg/dL eGFR 3. 6.73m2 BUN/Cr 14.Mo: History Dyspepsi gastrop omeprazole 1 x 40 nausea Newly Diagnosed with a athy mg Intravena CKD 1 day ago syndrom 7. CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 6.

UTI Injection P.1/hpf . CUE AND CLUE Problem Initial Planning Planning Therapy Pmo & List Diagnosis Diagnosis Pedu Male/69 YO 7.Mo: History asympto Ciprofloxacin nausea Newly Diagnosed with matic 2x200mg intravena CKD 1 day ago P.Edu:- Lab : Urinalisa : Leucosite : 25.

5 0C • SpO2 : 97 % room air • Urine Production 50 cc/4 hours ~ 16 cc per hour . Condition This Morning • GCS : 111 • BP : 110/75 mmHg • PR : 82 bpm • RR : 22 tpm • Tax: 36.

Thank You .