MORNING

REPORT
Date: 21 November 2023
th

Co-Assistant in Charge:
Raisah Hulaimah N.
(I4061222054)

Consultant:
dr. Rahmad Budianto, Sp. PD

1
 Summary of Data Base
Mr. FS/ 26 yo/ Emergency Room
Chief complaint: swelling in both legs
History taking: autoanamnesis

The patient came to the emergency room of the hospital

with a complaint of swelling in both legs for the past 2 days.
The swelling has not increased or decreased. There is no
swelling in other parts of the body.
The patient also complains of foamy urine for the past 2
days, which is light yellow in color. There is no pain during
urination.
Additionally, the patient complains of frequent pain in the
upper abdomen for a long time. The patient has a history of
gastric issues. The discomfort decreases after eating and
worsens if meals are delayed. Nausea is also present with these
complaints.
Past medical history :
He has been previously hospitalized and was diagnosed with nephrotic syndrome in
2020. He has a history of hypertension for the past 2 years (the highest BP was about
200/120). The patient regularly takes amlodipine 5 mg, candesartan 4 mg and
atorvastatin 20 mg.

Family History :
His father had hypertension

History of social and environmental :

He is married and does not have children yet. He works as a farmer. Before being
diagnosed with nephrotic syndrome, he used to consume carbonated drinks daily and
had a low intake of plain water.

History of allergy :
There was no allergic history of food nor medication
 PHYSICAL EXAMINATION
General appearance looked moderately ill Looked normoweight
GCS 456
BP=130/65mm PR = 65 bpm regular RR = 18 tpm Tax : 36,7 0C
Hg
Head Conjuctiva Anemic (-) Sclera Icteric (-)
Neck JVP R + 0 cm H20, 300 Lnn. Enlargement (-) Thyroid bruit (-)
position
Thorax Ictus invisible & palpable at ICS V MCL S,
Heart RHM ~ SL , LHM ~ ictus
S1 S2 single regular, murmur (–)
Lung Symmetric Stem Sonor + + v v Rh - - Wh - -
fremitus D=S ++ v v -- - -

++ vv -- - -
Abdomen Flat , Bowel Sound (+) N, a.renalis bruit (-), liver span 8 cm. troube’s space
tympani, Shifting dullness (-), epigastric tenderness (+)
Extremity Edema - / - Warm acral + /+ Rumple Leed Test (-)
+/+ +/+
 Laboratory Result
October 29th, 2023
Parameter Result Normal Value
Hb 16.9 g/dL 13.2 – 17.3 g/dL
Leucocyte 7000 /µL 3800-10600/µL
Hematocrit 49,7 % 4,4 - 52%
Thrombocyte 545.000 /µL 150.000 – 440.000 /µL
ESR 50 mm/h 0 – 10 mm/h
Natrium 141,43 mmol/L 135 – 147 mmol/L
Kalium 4,45 mmol/L 3,5 - 5 %
SGOT 15,8 0 – 50 U/L
SGPT 22,5 0 – 50 U/L
Albumin 2,08 g/dL 3.4 – 4,8 g/dL
HBsAg Non Reactive
Ureum 26,4 mg/dL 10 - 50 mg/dL
Creatinin 0.68 mg/dL 0,62 – 1,10 mg/dL
Urine protein 3+ Negative
CXR (October 29th, 2023)

• PA position, symmetric,
enough KV, enough inspiration
• Soft tissue normal, Bone
normal
• Trachea in the middle
• Hemidiagphragma D et S were
domeshaped
• Costophrenicous angle D et S
were sharped
• Lung : bronchovascular
pattern D et S were normal
• Heart : site normal, size CTR
<50%, shape normal

Conclusion : normal CXR

CUE and CLUE PL IdX PDx PTx PMo Ped
Mr. FS/ 26 yo 1. Low-salt diet Pitting Suggesting a
Edema and consume udem patient to
S/ swelling in ec. high essential degree follow a low-
both legs. hipoalb protein salt diet and
umin consume
O/ Pitting Albumin 25% high
edema degree 100 ml essential
2 (+/+) transfusion/ protein
Albumin: 2,08 day sources like
g/dL egg whites
Furosemid and
2x40 mg p.o snakehead
fish is a
recommenda
tion for
dietary
changes.
CUE and CLUE PL IdX PDx PTx PMo Ped
Mr. FS/ 26 yo 2. Chole consume high Urine The patient is
Nephrot sterol essential protein, given
S/ The patient ic test protein sources foam in education
complains of syndro like egg whites urine about
foamy urine. They me and snakehead nephrotic
also have a fish syndrome,
history of which can
Nephrotic Metil recur.
Syndrome. prednisolone Therefore, the
2x250mg inj. patient is
O/ urine protein : advised to
3+ Atorvastatin 0- undergo
0-20mg p.o regular check-
ups. It is
recommended
for the patient
to follow a diet
high in
essential
proteins, such
as egg whites.
CUE and PL IdX PDx PTx PMo Ped
CLUE
Mr. FS/ 26 yo 3. Low-acid and VAS Suggesting the
Dispepsi mild diet patient follow a
S/ upper a synd. low-acid and
abdominal Pantoprazole mild diet.
pain and 1x40 mg inj. Advising them
nausea. The to avoid
patient has a consumption
history of that can trigger
gastric excessive
issues. stomach acid,
such as coffee
O/ and tea
epigastrium
(+) tenderness
VAS: 5
CUE and CLUE PL IdX PDx PTx PMo Ped
Mr. FS/ 26 yo 4. HT Low-salt diet Blood Advising the
stg 2 pressure patient to
S/ He has a Ramipril follow a low-
history of 1x5mg p.o salt diet and
hypertension for Amlodipine to regularly
the past 2 years 1x5mg p.o take
(the highest BP hypertension
was about medication.
200/120).

O/ BP: 130/65
mmHg
Thanks you