MORNING REPORT

C4 Ward

A 60th year-old man was admitted to

R.D. Kandou Hospital at C4 ward on
July 13th 2016 at 18.30 WITA.
With main complaint:
Pain on left hand 1 week b.a

Patients identity
Name
: Mr SJ
Age
: 60 yrs
Sex
: Male
Occupation : Civil Servant
Education
: Senior High School
Ethnicity : Minahasa
Religion
: Protestan

Present Medical History

Patient was reffered by an internist in Manado
Pain on left hand since 2 days b.a. The
characteristic : tingling (+), cant be used,
swelling (+), eritema (+). The
Fever (-). Headache (-)
Defecating and urinating no complain

Past Medical History

History of hypertension (+), since 10 years
ago taking medication regularly
History of Renal Disease (+) since 10 years
B.a
History gouty (+), since 30 years ago
History of diabetes, asthma, kidney, liver
disease was denied

Family History
None experienced the same illness

History of allergy :
Unknown
History of immunization :
Unknown
Habit history :
Alkoholism (-) denied
Smoking (-) denied
Taking pain killer drug (-)

General anamnesis ( review of system )

General :
Skin : Head and neck : Eye
:Ear
:Nose
:Mouth and throat: Respiratory : Chest : Heart : -

Abdomen
: Nausea (+)
Genitalia : Kidney
:Hematology :Endocrine
:Musculosceletal : Pain on left arm
Neurology
:Psychology :-

Physical Examination

GC: Moderately ill. Sens : CM

ER :BP: 160/90mmH, PR 92x/m, RR 20x/m, T 36,8C
C4: BP: 190/100mmHg, PR 88x/m, RR 20x/m, T 36,2C
BW 60kg, BH 165 cm, BMI 22kg/m2
Head : conj. anemic (+/+), scl. icteric(-)
Neck : JVP 5+0 cmH2O
Thorax :
Heart :
Insp : IC not lookable

Palp : IC not palpable

Perc : left border: ICS V midclavicullar line
right border: ICS IV sternal line
Ausc : SI-II regular, murmur (-), gallop (-)

Physical examination
Lung : Insp : Symmetric R = L
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/ Abd :
Insp : Flat
Palp : Soepel, pain on epigastric (+), undulation (-)
Perc : Timpani, Shifting dullness (-)
Ausc : Bowel sound (+) normal
Extr : Regio MTP digiti 5 manus S, : odem +, rubor +, kalor +, dolor +
Oedma at left wrist (+), Tophi at extrimity (+)
Genital : RT : tonus sfingter ani +, mucosa smooth, ampula
empty, mass -, blood -, feces +

Lab Result
14/ 7/2016

Erit
3.49
Hb
10
Ht
30
Leucocyte
10.700
Platelet
261.000
MCV
91
MCH
31
MCHC
34
Ureum
94
Creatinin
11.68
GDS
96
Na
137
K
3.9
Cl
103
Uric Acid
10.1
Cholesterol Total 100

UL
Leu
Nit
Uro 0.2
Prot +++
pH 6.5
Blood SG 1.010
Keton Bil
Glu +

Problem List
No CM : 35.71.51 Age : 60 y.o
1. Main complain:

Pain on left arm feet since 1week b.a

2. Anamnesis:
Patient was reffered by an internist in Manado
Pain on left hand since 2 days b.a. The
characteristic : tingling (+), cant be used,
swelling (+), eritema (+).
History of hypertension (+), since 10 years ago
taking medication regularly
History of Renal Disease (+) since 10 years B.a
History gouty (+), since 30 years ago l

3. Physical examination
BP : 180/1000 mmhg
Eye : Conjungtiva anemis +/+
Abdomen : pain on epigastric +
Ext : regio MTP 1, maleolus lateralis :
rubor, kalor, dolor, tumor +
Multiple tophi at all extrimities

Lab Result
14/ 7/2016

Ureum
94
Creatinin
11.68
Uric Acid
10.1
Cholesterol Total 100

UL
Prot +++
Glu +

ECG : Sinus rhytm, HR 97 x/m

ECG INTERPRETATION
ECG components

Interpretatio
n

Value

Rhythm

Sinus rhythm

Sinus Rhythm

Speed / HR
(times/mnt)

75x/min

1500/R-R

Axis

Normal

Normal / RAD / LAD

Morphology P wave

0,08 sec

Lead II : Duration 0.10, Height

2.5

PR Interval

0,20 sec

0,12 0,20

QRS complex
duration

0,08 sec

0,05 0,11``

ST segmen

Isoelectric

Normal / Elevated / Depressed

T wave

Normal

Normal / abnormal

QT Interval

0,33 sec

cQT = QT interval / vR-R

Interval

U wave

Absent

Appear / not appear

CONCLUSION : Sinus rhythm, 97 bpm,

Xray
Thora
x

Roentgen INTERPRETATION
Roentgen Componen

Interpretation

Identity

Same

KV

Normal

Symmetric

Symmetric

Trachea

Normal

Diaphragma

Normal

Sinus Costophrenicus

Sharp

Sinus Cardiophrenicus

Sharp

Bone

Intact

COR - CTR

CTR 57%

Pulmo Parenchym

Normal

CONCLUSION : Cardiomegaly

Patients photo

N
o

Problem List

History of
arthritis + 30
years ago

Plan Dx

Plan Tx

Uric Acid
LED

Paracetamol
tab 3 x 500
mg k/p
Metil
Prednisolon
2x125 mg
Tramadol 3x1
tab

Diet low
purine
Mobilisation
Hot or cold
compress

Vital sign
monitoring

Amlodipin
1x10 mg
Candesartan
1x8 mg
Clonidin
3x0,15 mg

Low salt diet

Education
about the
illness and
complication

Ext : Multiple
tphi
Leu :

Non pharm
th/

Plan
Monitoring

Gouty arthritis
acute exacerbation
2

BP : 180/100
mmhg
History of
hypertension,
routine
comsumption
drug
Hypertension
urgency

Ro thorak PA
ECG
Na,K,Cl
UL
Consuly to
Eye
Department
Consult to
Neurology
Department
Consult To

Vital sign
monitoring
Urine output

N
o

Problem List

History of gouty
arthritis + 30
years ago,
hypertension
BP : 180/90
mmhg
BUN : 94
Creatinin 11.68
UL : prot +
BUN/cr : 7.83
eGFR EPI : 4.9

Plan Dx

Plan Tx

USG
Abdomen
Kidney

Aminefron 3x1 Diet prot 0,8

tab
gr/kg/d
Diet kal 35
Renal
kcal/kg/d
Ca, Mg, P, Na, Replacement
K, Cl, prot
Theraphy
Educate the
T/A/G,
denied by
family about
patient.
the condition
of the patient
and plans
ahead.

Hyperkalemi ECG
a

Inj Ca
Gluconas 1
Amp

K : 5.6
ECG : Tall T (-)

Plan
Monitoring
Vital sign
monitoring
Electrolyte
control
Urine output

Educte to
consume
medicine
regulary

CKD 5 ec dd/
gouty nephropathy

Non pharm
th/

Kalitake 3x1
sachet
Ventolin

Educate the
family about
the
condition of
the patient
and plans
ahead.

Observation
for vital signs.
Kalium
Control

Eye : CA +
Hb 10.0
Anemia renal
dd/ occult
bleeding

Blood
smear
Faeces
analysa +
benzidine
test
SI, TIBC,
feritin

Folic acid
3x1
Pro
tranfusion if
hb < 8

control Hb

Conclusion
Male 63 yo come to RD Kandou
hospital with main complain pain in
the left arm since 4 day ba. The
working diagnosis are Acute
Exacerbation of Gout, Hypertension
urgency, Chronic Kidney Disease
Stage V, Hiperkalemia, Anemia e/c
Anemia Renal.

Thank You

HypoNa