Morning Report

Saturday Night, Juli 6rd 2019

VAS/MIY/TEB

WARD
No Name Gender,Age Working Diagnosis
1. SD Boy , Sindrom Nephrotic DD/ GNAPS
2 years, 3 DD/ Sindrom Nephritic
months
1
New Patient admitted at Emergency Room at 13.00 PM, SD, Boy , 2 Years 3
Month. Address :
BW : 16 kg BL : 82 cm
W/A : Z > 3 , H/A 0< Z< 2 , W/H = -3< Z < -2 , Ideal weight 11 Kg

Chief complain : swelling

-Swelling all over the body since 7 months ago, the swelling never goes away
even with medication. Swelling start from the eyes on the face and then spread
to all of the body.
-History of of fever, sore throath, runny nose, and shortness of breath was
denied.
-There was cough and shortness of breath especially at night in bed time.
-History of skin infection was denied.
-History nausea and vomiting was denied.
-Stool and urination was normal
-No history of family with same complain
• History of previous illness

Patient once was patien from Pringhadi Hospital and diagnosed with Nephrotic
Syndrome

• History of previous medication : Prednison and lasix

• Pregnancy history:
This patient was the second child. No medical conditions such as high fever,
diabetes, and hypertension during pregnancy. No history of drugs and
traditional medicine consumption during pregnancy. Antenatal care was done
routinely by midwife.
• Delivery history:
The patient was born term, assisted by midwife, respectively. He cried
spontaneously after birth without history of cyanosis. Immunization and
vitamin K injection were uncertain.
Physical Examination
General status :
Sensorium : Compos mentis Temperature : 36,50C
dyspnoe (-), cyanosis (-), edema (-), icteric (-), anemic (-)

Localized status:
Head : pale face
Eye : Light reflexes (+/+), isochoric pupil, Ø3mm/3mm, pale inferior
palpebral conjunctiva (-/-), icteric sclera (-/-), edema (+/+)
Ear : within normal limit
Nose : within normal limit
Mouth: pale lips mucosa (-)
Neck : lymph node enlargement (-)

Thorax : Symmetrical fusiform, no retraction, edema was found

Heart rate : 120 beat/minute, regular, murmur was not found
(N : 60-120 bpm)
Respiratory rate : 28 times/minute,regular, minimal rales +/+, stridor and
wheezing was not found

Abdomen : soepel, peristaltic sound (+) normal, massive asites was found
Lien and Hepar was hard to assest
Extremities: Pulse 120 bpm, regular, normal pressure volume adequate,
warm extremities, CRT< 2 second, edema was not found
Blood pressure : 110/70 mmHg ( 87-102 / 41 – 57 )
Saturation O2 96-98%
 Laboratory Results from Tiara Kasih Sejati Hospital
July 6th 2019

• HGB : 6,9 g/dL

• HCT : 21 % • Ca : 3.9
• WBC : 13.060 /mm3 • K : 3,7 mEq/L
• PLT : 627.000 /mm3 • Na : 137 mEq/L
• MCV : 77 • Cl : 105 mEq/L
• MCH : 24.8
• MCHC: 32.2 • Urine Dipstick : Protein +3,
• BUN : 12, UR/CR : 26/0,47 PH 6.6, blood +2

• Albumin : 1.0 g/dL

Differential Diagnosis :
Sindrom Nephrotic
GNAPS
Sindrom Nephritic
Working diagnosis :
Sindrom Nephrotic
Therapy :
- IVFD D5 % NaCl 0,225 % 4 gtt/m
-Inj. Furosemide 5mg/12 h
-Calcium correction
-PRC transfusion
-Albumin substitution 25% 11 cc in 4 h

Planning :
- Consult to Nefrology division, check Lipid profile, C3
Time Sens BP HR RR Sat.O2 Temp Additional
16.00 GCS 100/60 174 bpm 64 bpm 94% 36.8
10
17.00 GCS 100/60 178 bpm 64 bpm 93% 37
10
18.00 GCS 100/60 176 bpm 60 bpm 94% 37,4 Blood sample drawn
10
19.00 GCS 100/50 175 bpm 64 bpm 94% 37,2
10
Thank You