MORNING REPORT

Wednesday, October 21 th, 2015

Coass in Charge
Hamdhani W
Triandra DS
Supervisor
dr. Didi Candradikusuma, SpPD

Summary of Data Base

Mr. M. Taufik/43 yo/W.22

Chief complain: Nausea and vomiting
Patient suffered from nausea since 6 months ago
and accompanied with vomiting since 3 days before
admission, 2 - 3 times per day, volume 1 glass of
mineral water each vomit, not projectile contain of
water. Because of this condition, patient suffered
from decrease of appetite since 2 weeks ago, eat
about 5 6 spoon of pooridge every day and the
patient looked skinny.
Patient also felt week since 3 weeks ago, gradually
onset, but the patient still can walk.
Patient has diagnosed with hypertension since 1
years ago, the highest blood pressure was 200/..

Past medical history :

He was hospitalized at Prima Husada hospital for 5 days and
referred to RSSA with the same complain but he did not
know the drug that was given by the hospital
The patien cannot passing stool since 2 week ago, urinate
only 3 times/day 100 cc each
Family history :
His 2nd, 3rd, 4th brothers suffered from Diabetes and
hypertension
Social history :
Work as factory labour, divorced, has one child.
Smoking (-), alcohol (-)

Physical examination
General appearance , moderately ill

looked normoweight GCS 456

BP = 120/60 mmHg

PR = 93 bpm

RR = 18 tpm

Head

Anemic
conjungtiva (+)

Sclera icteric -

Neck

JVP R +3 cm H2O 30,

Thorax:

Cor:

Lung:

Tax = 36 C

Invisible and palpable at ICS V MCL S

RHM PSL sinistra
LHM ictus
S1, S2 single reguler
Symmetric, SF D = S v v
v v
v v

Rh - - - -

Wh - ---

Abdomen

Flat, soefl, BS + normal, liverspan 8 cm, troube space tympani,

shifting dullness (-), abdominal tenderness (+)

Extremities

Warm, extremity edema -/-

CXR
20th October 2015

Chest X-Ray
20th October 2015
AP position, asymmetric, less KV, enough inspiration
Soft tissue : normal, barrel chest (semifowler position)
Trachea in the middle
Right and left hemidiaphragm: dome shaped
Left and right phrenico costalis angle: sharp
Lung : Bronchovascular Pattern Normal
Heart : site normal, CTR 51%, shape normal

Conclusion : Normal

ECG (20th October 2015)

ECG
20th October 2015
Sinus rhythm, heart rate 66 bpm
Frontal Axis

: normal

Horizontal Axis

: normal

PR interval

: 0.16

QRS complex

: 0.08

QT interval

: 0.32

Tall T at lead II
Conclusion : sinus rhythm,with heart rate 66 bpm

LABORATORY FINDING
Lab

Value

Leukocyte

7460

Haemoglobine

(Normal)

Lab

Value

(Normal)

4.700 11.300
/L

Natrium

136

136-145 mmol/L

6,2

11,4 - 15,1 g/dl

Kalium

7,24 (ER)->
5,20 (Ward)

3,5-5,0 mmol/L

Hct

18,5

38 - 42%

Chlorida

113

98-106 mmol/L

Trombocyte

83.000

142.000
424.000 /L

RBS

106

< 200 mg/dl

MCV

73,40

80-93 f

Ureum

516,8

20-40 mg/dL

MCH

24,60

27-31 pg

Creatinine

22,89

<1,2 mg/dL

Eo/Bas/Neu/limf/
Mon

2,5/0,1/76,4/17,
2/3,8

0-4/0-1/51-67/2533/2-5

eGFR

3,5
mL/min/1,7
3m2

SGOT

14

0-32

Calcium

9,6

7,6 11,0mg/dL

SGPT

10

0-33

Phospor

6,0

2,7 4,5 mg/dL

Uric acid

7,3

2,4 -5,7 mg/dL

Albumin

3,17

3,5-55 g/dL

Urinalisis
Lab

Value

Urinalysis

Clear yellow

Lab
10 x

Value

SG

1,015

Epithelia

0,9

PH

5,5

Cylinder

Leucocyte

Hyaline

Nitrite

Granular

Protein

2+

Leukocyte

Glucose

Erythrocyte

Erythrocyte

1+

40 x
Erythrocyte

4,4

Keton urine

Leukocyte

2,1

Urobilinogen

Crystal

Bilirubin

Bacteria

25,9 x 103 mL

CUE AND CLUE

Male/43 yo /W22
Diagnosed as Hypertension
Nausea and vomiting
Weakness
PE:
Dry skin
Conj anemis +
JVP = R + 3 cmH20 (30)
Cor: ictus ICS V MCL S
Lab:
K 7,24 mg/dL(ER)-> 5,2 mg/dL
(Ward)
Ur 516
Cr 22,89
eGFR 3,5 ml/mnt/1.73m2

PL
1. Severe
hyperkale
mia
(resolved)

IDx
1.1 dt CKD

PDx
-

PTx
-Low Kalium Diet
-Correction : 3 cycles (ER)
Injection Calcium Gluconas
10 mg iv
Injection D extrose 40% 2
Flash iv
Injection Actrapid 10 IU iv
-Calsium Polystyren
Sulfonate 2x 5 gr (PO)

Pmo

P edu

S, VS,
Electrol
yte
serum
post
correct
ion

Conditi
on and
compli
cation

CUE AND CLUE

Male/43 yo /W22
Diagnosed as Hypertension
Nausea and vomiting
Weakness
Look pale
PE: GCS 456
BP 120/60 mmHg
PR bpn
RR 16 tpm
Dry skin
Conj anemis +
JVP = R + 3 cmH20 (30)
Cor: ictus ICS V MCL S
Lab:
Hb 6,20 gr/d
MCV 73,4 fL
MCH 24,8 pg
PLT 83.000
K 7,24
Ur 516
Cr 22,89
eGFR 3,5 ml/mnt/1.73m2

PL

IDx

PDx

2. CKD
stage 5
newly
diagnosed

2.1 hypertension
nephrosclerosis

Abdomin
al USG

PTx
O2 2 - 4 lpm NRBM
Bed rest
Equal fuid balance
diet 1700 kcal/day, low salt
< gram/day, protein 0,6-0,8
g/kgbw/day
Iv plug
Furosemide 40-0-0 mg (iv)
Elective HD

Pmo

P edu

VS
Compl
ain
Urine
produc
tion

Fluid
restrict
ion,
explan
ation
about
renal
replace
ment
therap
y

CUE AND CLUE

Male/43yo/W22
Ax
Nausea and vomiting
Decrease of appetite
Low intake
Weakness
PE:
Epigastric tenderness +
Lab:
Hb 6,20 gr/d
MCV 73,4 fL
MCH 24,8 pg
K 7,24
Ur/Cr 516/22,89
eGFR 3,5 ml/mnt/1.73m2

PL
3. Dyspepsia
Syndrome

IDx

PDx

3.1 Uremic
gastropath
y
3.2 PUD

Endoscop
y

PTx
Inj. Omeprazole 1x40
mg Iv
Inj. Metoclopramide
3x10 mg iv

PMo
Subj.
VS

P edu

CUE AND CLUE

Male/43yo/W22
Ax
Weakness
Decrease of appetite
Look pale
PE: GCS 456
BP 120/60 mmHg
Conj anemis +
JVP = R + 3 cmH20 (30)
Cor: ictus ICS V MCL S
Lab:
Hb 6,20 gr/d
MCV 73,4 fL
MCH 24,8 pg

PL

IDx

PDx

4. Anemia renal

4.1 Deficiency
EPO
4.2 Deficiency Fe
4.3 Chronic
disease

SI
TIBC
Sat
Transf
erin

PTx
PRC Tranfussion 1 pack
durante HD

PMo

P edu

Subject
Vital sign
Bleeding

Patient
conditi
on,
progno
sa and
manag
ement

CUE AND CLUE

PL

IDx

Male/43 yo /W22
Diagnosed as
Hypertension
Hystory of Blood pressure
200/
PE:
PE: GCS 456
BP 120/70 mmg

5. Hypertension
stage 2 on
treatment

5..1 primary
5.2secondary

Male/43yo/W22
Ax
Cannot pasiing stool
for 1 week
Low intake
Low fiber diet

6. Constipation

6.1 Low intake

PDx

PTx

PMo

P edu

Po.
Amlodipin 1x10mg

Vital sign
Blood
pressure

Conditi
on
Progno
sed

High fiber diet

PO
Laxadyn Syr 3 x CII

Constipati
on

High
fiber
diet

THANK YOU