MORNING REPORT

August, 18
th
2014


Consulen:
Dr I Nyoman Suarjana, Sp,PD-KR
DATA OF PASIEN
Name : Mr. F
Sex : Male
Age : 34 yo
Race : Banjar
Address : Kalsel



ANAMNESIS
Chief complain : Shortness of breath (SOB)
Patient has been complaining about SOB since one day
before coming to the hospital. This complain rise
gradually and become severe so the patient brings his
self to hospital. He cannot do his activities like usual.
Patient also complain about nausea and vomitus since 3
days ago that beginning by epigastric pain. The pain
didnt referred to another regio. Patient also feel weak
cause he didnt eat since 3 days. There was a complain
about a headache too. Patient has a medical record of
Chronic Kidney Disease and get routine haemodialysis 2
times/week since 8 months ago.

History of illness : CKD(+), DM(-), HT(+)
History of family illness: (-)
Physical Examination
General
Looks : Modereate illness
Awareness : Compos Mentis
GCS : 4-5-6
BP : 160/100mmHg right arm
Pulse : 90x/minute,
RR : 30x/minute
T : 37,1
o
C

Physical Examination
Skin : Skin turgor normal , rash (-),
ikterus(-), hairfall(-)
Head : normosefali, pain(-)
Eye : pale konjungtiva (+/+), edem
palpebra(-/-), sklera ikterik(-)
Ear : deformitas(-), otoreea(-),
tragus pain (-), mastoid pain(-)
Nose : Deviation (-), rinorreha(-)
Mouth : Lip mukosa normal, sianosis(-),
thypoid tongue(-), hiperemis
lip(-).
Throat : tonsilitis(-)
Neck : JVP (-), P> KGB (-), P> tiroid(-),
pain (-)
Physical Examination
Thorax
gynecomastia(-), sekret(-), massa(-), spider naevi(-)
c0r
ictus visible,
palpationi ICS V LMC S, cardiac waves(-)
Right margin LPSD ICS II-IV, Left margin LMCS ICS V
S1 S2 single, murmur (-), gallop (-)
p/ Ins : retraksi (-)
Pa : FV Simetris
Per : S S
S S
S S
Aus : V V rh - - Wh - -
V V - - - -
V V + + - -

Physical examination
Abdomen :
I : Cembung , venektasi (-), caput medusa(-), sikatrik(-)
Aus : Intestine sound normal.
Pa : Hepar normal, Lien normal, shifting dullness(-), undulasi (-)
Pain - + -
- - -
- - -
Per : T T T
T T T
T T T
Extremity : deformitas(-), palmar eritem(-)
edema - - akral dingin - -
+ + - -

Lab finding
Hb = 8,7 gr/dl ()
Leukosit = 8.300/dl (N)
Eritrosit = 2.600.000/dl ()
Hematokrit = 26,9 vol% ()
Trombosit = 203.000/dl (N)

SGOT = 34 U/l (N)
SGPT = 21 U/l (N)

Ureum = 116 mg/dl ()
Creatininin = 9,7 mg/dl ()

Na
+
= 134,1 mmol/l ()
K
+
= 4,9 mmol/l (N)
Cl
-
= 99,6 mmol/l (N)

Resume basic data
Anamnesis:
SOB (+) nausea and vomit (+) Anorexia(+), Epigastric pain(+),
weak (+), headache (+), history of CKD (+), history of HT (+)

Physical Exam :
BP= 160/100 mm/Hg, RR= 30x/minute, pale konjungtiva (+/+),
rhonki (+), epigastris pain (+), inferior extremitas edema (+)

Lab:
Hb = 8,7
Ureum = 116 mg/dl
Creatininin = 9,7 mg/dl
Problem List
1. CKD grade V on HD
2. Hypertension stage II
PROBLEM LIST
No. Problem Supporting Data
1.














2.
CKD grade V on HD














HT stage II
Anamnesis:
SOB (+)
nausea and vomit (+) Anorexia(+)
Epigastric pain(+)
weak (+)
history of CKD (+)

Physical exam:
RR= 30x/minute
pale konjungtiva (+/+)
rhonki (+)
epigastris pain (+)
inferior extremitas edema (+)


Anamnesis:
Headache (+)
history of HT (+)

Physical exam:
BP = 160/100 mmHg
Planning Dx and Tx
1. CKD grade V on HD
- Planning Dx : -
- Planning Tx : venflon (+)
O2 2 lpm
inj. Lasik 1-0-0
Asam folat tab 3 x 1
CaCO3 tab 3x1
Continue the routine HD
- Education : restriction the water
Planning Dx and Tx
2. Hypertension stage II
- Planning Dx : -
- Planning Tx : Captopril tab 3 x 25 mg
- Education : restriction the salt and
cholesterol
THANK YOU