MORNING REPORT

dr. aAlul- IPD

June, 4th 2015

PHYSICIANS INCHARGE:
• IA : dr. Handy and dr. Reza (cardio)
• IB : dr. Norma
• II : dr. Alul (HCU),dr. Iman(CVCU)
• ER : dr. Rahmi and dr Reggy
• Chief jaga : dr. Asri
• Consultant : dr. Niniek B, Sp.PD-KPTI
 SUMMARY OF DATABASE
Mrr. Minarti/ 40 Years old/ Ward 26
Chief complaint : shortness of breath
Autoanamnesis

Patient suffered from shortness of breath since 1 week before admission, suddenly onset, and
make him felt weakness and activity limitation. The shortness of breath was not ascosiated with
activities.

Patient also suffered from general weakness since 3 month ago but worsening in the last 1
week. She was only taking rest at her home

Patient also sufferd from nausea and vomiting since 3 month ago, she usually felt nausea every
she want to eat. The vomiting was containing liquid and residual food, she vomited 2-3 times/day.

Patient also felt that her urination was getting decrease.she said that her total urination in the
last 1 week was about 500 cc/24 hours
• She had been diagnosed as CKD since 3 moth
ago, and she was suggested to underwent HD,
but patient refused at that time
• Patient also suffered from blactarry stole 1 week
ago for 3 days, and then got medication from
previous hospital
• History of past illness : she never had been hospitalied before
• Familly history: her mother had died because of Hypertension
• Her father was died because of atshma
• Social history:
married, have 2 children, allergy (-), used contraception
hormonal inj. History of using traditional potion and also NSAID
to relieve her muscle pain after working.
 PHYSICAL EXAMINATION
General Appearance: looked pale and moderatelyy ill Looked underweight

BP : 160/100 mmHg ER)

GCS: 4.5.6 PR: 120 bpm RR: 24 tpm Tax: 36.50 C
110/70 mmHg (ward)

Head anemic conjunctiva +, icteric sclerae -, lnn enlargment (-),

Neck JVP R+2 cm H2O.

Heart
Ictus invisible, palpable at ICS VI 2 cm MCL S Trill: - Heaves: -
Chest RHM ~ SL D LHM ~ ictus
S1 and S2 single, murmur(-)

Stem Fremitus D=S Sonor Sonor v v Rh -- Wh --

Lung Sonor Sonor vv -- --
Sonor Sonor vv -- --
soefl, bowel sound normal, tendernes -, liver span 8 cm, Traube’s space tympany, shifting dullness -, flank pain
Abdomen D/S (-)
Warm, edema -/- , refleks patologis (-) parese - - motoric ( 5 5), sensoric (N)
Extremities +/+ -- 55
 LABORATORY FINDING (November 4th 2016)
Lab Value (Normal) Lab Value (Normal)
Leukocyte 5800 4.700 – 11.300 /µL Natrium 139 136-145 mmol/L

Haemoglobine 4.7 11,4 - 15,1 g/dl Kalium 3,90 3,5-5,0 mmol/L

PCV 13.9 38 - 42% Chlorida 108 98-106 mmol/L

Trombocyte 86.000 142.000 – 424.000 Ureum 227103.10 20-40 mg/dL

/µL
Creatinine 12.76.89 <1,2 mg/dL
eGFR 7 ml/min/1.72m2
ml/min/1.73
m2
MCV 85.,30 80-93 fl GDS 124 <200

MCH 27-31 pg Ca 7.6-11.00 mg/dL

28.80 8.1

Eo/Bas/Neu/limf/Mon 0,0/0.1/86.41/4, 0-4/0-1/51-67/25- Phospor 2.7-4.5 mg/dL

5/9.1 33/2-5 14.7

SGOT 0-32 mU/dL albumin 3,72 3,5-5,5

123

SGPT 0-33 mU/dL HbsAg Non reactive non reaktif bila S/CO: <1,00
106
Lab Value (Normal) Lab Value (Normal)
PPt
Patient 11,10 9,3-11,4
INR 1,07 0,8-1,30
APTT
Patient 29,1 24,8-34,4
 BGA (November 3 2016) th

Temp 37,0 °C O2 8 lpm (NRBM)

PH 7.26 7.35-7.45
PCO2 19.8 35 – 45 mmHg
PO2 74.1 80 – 100 mmHg
HCO3 9 21 – 28 m mol/L
O2 sat Art 92,9% > 95 %
BE -18.3 (-3) - (+3) m mol/L

Conclusion : ascidosis metabolic partially compensated

with alkalosis respiratoric
 URINALYSIS ( NOV 3TH 2016)
LAB VALUE LAB VALUE
Turbidity 10 x
Colour SLIGHT CLOUDY Epithelia 0,3
PH 6.0 Cylinder -
SG 1,015 Hyaline -
Glucose - Granular -
Protein +3
Keton - 40 x
Bilirubin - Erythrocyte 1.3
Urobilinogen - Leukocyte 14.7
Nitrite - Crystal -
Leucocyte +1 Bacteria 4,6
Blood 1
3th November 2016
 CXR (Nov 4th 2016)
• AP position, asymetric, strong KV, enough inspiration
• Soft tissue normal, Bone normal
• Trachea in the middle
• Hemidiaphragma D was covered by radioopaq shadow
and S was covered by cardiac imaging
• Sinus costophrenicus was sharp and S was covered by
cardiac imaging
• Pulmo : bronchovesiculr pattern was increase
• Cor : site, shape normal and size: CTR 65%
• Conclusion : looked cardiomegally with lung oedema
 ECG (November, 4th 2016)

• Sinus tachycardia, Heart rate 115 bpm

• Frontal Axis : normal
• Horizontal Axis : clock wise rotation
• PR interval : 0,20”
• QRS complex : 0.08”
• QT interval : 0.32”
• Tall t wave at lead v2-v5
Conclussion: sinus tachycardia with heart rate 104 bpm,
hyperkalemia
 Clue and cue Planning
Problem list Initial Dx Diagnosis Therapy Monitoring Education

Female/40years old 1. Shortness of 1.1 Alo non NT PRO BNP Bed rest semi Subjective Explained
Shortness of breath
breath cardiogenik fowler position recent
Had been diagnosed 1.1.uremic lung Vital sign condition,
as ckd 1..2 Severe O2 8-10 lpm management,
History of black tarry Anemia Nasal canul BGA/6 hour and prognosis
stlole 1.2 ALO
BP: 160/100 mmHg cardiogenik Urine output
PR: 98 bpm IV plug
RR: 28 tpm Fluid balance
SaO2 98% with O2
10 lpm NRBM ECG
Pale conjungtiva (+)
Rhonkhi in
mediobaal of the
lung at ER
Hb: 4.7gr/dl
MCV/MCH:859/28.3
UR/CR 227/12

CXR: looked
cardiomegally
 Clue and cue Planning
Problem list Initial Dx
Diagnosis Therapy Monitoring Education

Female/40 years old 2 .Chronic 2.1 HT Abdominal USG Same as above Subjective Explained recent
Kidney Disease nephrosclerosis Vital sign condition,
Shotrtness of breath stage 5 2.2 PNC CCT Diit 1700ccal/day, Serum management,
HT (+)
Nausea vomitting low salt < 2g/day, electrolyte and prognosis
protein 30g/day (Na, K,Cl,Ca,P)
BP: 160/90 mmHg Urine
PR:98 bpm Balance (-) 500- production
RR: 28 tpm 1000 cc/24 hour
Pale conjungtiva (+) Ureum,
Rhonkhi in all of area
of the lung Inj. Metoclopramide creatinin
Edem ekst inf D/S 3 x 10 mg
Uric acid
Wbc: 22.540 CaCo3 3 x 500 mg
Hb: 8.7 gr/dl
MCV/MCH:69.9/27.3
Neutrofil 94.1% Plan for HD
UR/CR 162.5/8.49
eGFR 7.11
ml/min/1.73 m2

Phosfor 14.7
BGA: ascidosis
metabolic fully
compensated

CXR: looked
cardiomegaly with
lung oedema
Clue and cue Planning
Problem list Initial Dx Diagnosis Therapy Monitoring Education

Female/40year 3.Severe 3.1 Blood loss Blood smear Plan to give Subjective CIE about
s old Anemia 3.2.Deficiency PRC CBC condition,
normochromic eritropoetin SI trnasfusion 1 treatment and
Diagnosed normocytair 3.3 decreasing pack at ward prognosis
renal failure TIBC and then
since 3 month erytrocye life continued
ago span ferritin transfusion 2
Conjungtiva pack durante
anemis (+) HD
HR 120 bpm
BP: 160/90
mmHg
Lab :
Hb: 4.7 gr/dl
MCV/MCH:85.
9/28.3
Clue and cue Planning
Problem list Initial Dx Diagnosis Therapy Monitoring Education

Female/40 4. 4.2 USG doppler Low salt diet Subjective Explained

years old Hypertension renoparench renal artery less than 2 recent
stage 2 ymal gram per day Vital sign condition,
Hypertension hypertension Funduscopy management
(+)since 5 , and
years ago 4.1 amlodipin 1 x prognosis
Not routinely Renovascular 10 mg
controlled hypertension Clonidin 3 x Salt and fluid
0.15 mg restriction
BP: 160/100
mmHg

ECG: sinus
tachycardia
with HR 104
bpm
Clue and cue Planning
Problem list Initial Dx Diagnosis Therapy Monitoring Education

Female/40 5. 5.1 related to USG doppler Correction SE post Explained

years old Hyperkalemi CKD renal artery for correction recent
Kalium a (resolved) hyperkalemia condition,
7.06 Funduscopy Inj Ca management
6.573.90 gluconas , and
10% prognosis
ECG: Tall T Inj short ac Avoid food
wave at lead ting insulin containig
v2-v5 10 iu high K
D40% 50 ml
HD if there
was
reffrakter
hyperkalemia
 CONDITION THIS MORNING
• GCS: 4-5-6
• BP: 120/80 mmHg
• RR: 24 tpm
• PR: 90 bpm
• Tax: 36.2 0 C
• SaO2 98% with O2 2 lpm NC
THANK YOU