MORNING REPORT

MARCH 22ND 2017

SUPERVISOR: dr. Soroy Lardo, Sp.PD FINASIM

DOCTERS ON DUTY: DR. ANA
COASS ON DUTY: SARAH JIHAAN AND GESTI CHAERUNNISA
DEPARTEMENR OF INTERNAL MEDICINE INDONESIA ARMY
CENTRAL HOSPITAL GATOT SUBROTO
PATIENT RECAPITULATION
Mrs Fitri Widyaningsih/40th/Melena
multiple + Hipokalemia + Hipoalbumin
Mrs Amang/62nd/Anemia acute on CKD
Mr Rahmat/Aplasctic anemia
PATIENTS IDENTITIY
NAME : Mrs. Amang
SEX : Female
AGE : 62nd years old
OCCUPATION : retired
ADDRESS : St Kalibiru Timur No.3
Jakarta Utara
DATE OF ADMISSION: Wednesday 22 nd
2017
ANAMNESIS
Autoanamnesis on March 22 nd 2017

CHIEF COMPLAINT
General weekness 1 day ago
HISTORY OF PRESENT
ILLNESS
Patients was admitted with general weekness all of his body since
1 months. At first, patient can do the daily activities by herself. Her
complain become worsen since 1 day ago till she could not
continue her activities. She also complained of having nausea and
vomit with water and food one time. It comes reappear. She
denied chest pain
Patient also complain low back pain that move to her stomach.
Scala of pain is 6.
There were no complain of micturition and defecation the quantity
are within normal limit. Fluid balance of input and output was
equal.
The mass is on the roof of the mouth. Patient loses her weight so
quickyl during 1 month, from 65 kg to 50 kg.
Patient has been hospitalized RS Koja 1 month ago with the same
clinical manifestations.
PAST ILLNESS HISTORY
Uncontrolled hypertention since 1 year
ago
Cardiac disease (-)
Diabetes (-)
FAMILY ILLNESS HISTORY
No family member with the same
symtpom
Hypertension, diabetes, cardiac illness,
allergy (-)
PHYSICAL EXAMINATION
General Examination
General condition:good

State of Consciousness: compon mentis

Vital sign

- Blood pressure: 140/60 mmHg

- Heart rate: 117 x/mnt
- Respiratory: 22 x/mnt
- Temperature: 38.8
Body weight: 50 kg

Body height: 153 cm

Body mass index: 21.36 normal

 Head : Normocephal
Eye : anemis conjungtiva (+/+),
icteric sclera (-/-)
Ears : normotia, discharge (-)
Nose : septum deviation (-), discharge
(-)
Mouth : normal tongue, hyperemic
phariynx (-), T1-T1
Neck : lmyp nodes enlargement (-)
 Thorax
Pulmonary examination

- Inspection: symmetrical lung movement, scar (-)

- Palpation: symmetrical chest expansion and vocal fremitus,
mass (-), tenderness (-)
- Percussion: sonor at both lung field
Auscultation: vesicular breath sound, crackles (-), wheezing (-)

Cardiac examination
- Inspection: ictus cordis not visible
- Palpation: ictus cordis not palpable
- Percussion: right cardiac border at ICS IV right parasternal line,
left cardiac border at ICS V left midclavicular line, upper border
at ICS III left parasternal line
- Auscultation: normal S!/S2 regular, no murmur, no gallop
 Abdomen
- Inspection: flat, no skin lession/scar
- Auscultation: bowel sound (+) 3 times per minute
Percussion: tympani on four abdominal quadrant,

shifting dullness (-)

Palpation: Supple, skin turgor (+), tenderness on

epigastrium, liver and spleen not palpable

Extremities: CRT <2 seconds, warm distal

extremities, no edema, no deformities
 Laboratory examination

Result Normal Range

Hb 6* 13 18 g/dL
Ht 17* 40 52 %
Eritrosit 2.1* 4,3 6,0 juta/uL
Leukosit 5650 4800 10800 / uL
Trombosit 220.000 150000 400000 / uL
 Result Normal Range
MCV 81 80 96 fL
MCH 26 27 32 pg
MCHC 35 32 36 g/dL
Kimia Klinik
Ureum 169* 20-50 mg/dl
kreatinin 9.1* 0,5-1,5 mg/dl
Random Blood 101 <140 mg/dl
Glucose
Resume
Patients was admitted with general weekness all of his body
since 1 months. At first, patient can do the daily activities
by herself. Her complain become worsen since 1 day ago till
she could not continue her activities. She also complained
of having nausea and vomit with water and food one time.
It comes reappear. She denied chest pain. Patient also
complain low back pain that move to her stomach. Scala of
pain is 6. There were no complain of micturition and
defecation the quantity are within normal limit. Fluid
balance of input and output was equal. The mass is on the
roof of the mouth. Patient loses her weight so quickyl during
1 month, from 65 kg to 50 kg. Patient has been hospitalized
RS Koja 1 month ago with the same clinical manifestations.
List of Problems
CKD
Anemia
Renal Colic
Observation febris day 1
Assessment

Anemia
Base on
Anamnesis: general weekness,headache
Physical examination: conjungtiva anemis
+/+
Lab examination: Hb: 6, Ht 17, eritrosit
1,7, MCV MCH MCHC normal
Assesment: transfusi PRC 900 cc
 CKD
Anamnesis: Past hyptention, weak, nausea
and vomit
Physcal examination: Hb 6, ht 17,
ureum169 kreatinin 9,1
Assesment: check AGD, USG abdomen,
rontgen thorax, hemodalisis
 Renal colic
Anamnesis: low back pain move to
stomach 1 week ago
Assesment: abdomen rontgen
Monitoring: Pain scale
 Angulus kostovertebralis: Sudut yang dibentuk oleh tepi
bawah iga ke-12 dan prosessus transversum vertebra atas
 Febris observatioon day 1
Based on:
Physical exmination: T:38.8
Assessment: check ul, diff
count,paracetamol tab 1x500 mg
Monitoting: vital sign
Prognosis
Quo ad Vitam : Dubia ad bonam
Quo ad Functionam : Dubia ad bonam
Quo ad Sanationam : Dubia ad bonam