MORNING REPORT

Thursday, 20th July 2017

Mentor:
dr. Dikara, Sp.PD

Presented by :
Annisa, Nadia, Nafisah and Luthfi
 Patient Identity
Sex : Female
Name : Mrs. D
Age : 25 y.o
Occupation : Housewife
Hospitalized since : July, 20th 2017
 Resume of Medical Record

Chief complaint: foot oedem

The patient come from RS Sampit and complained edema of legs since 1 week a go,
appear slowly but progressive. Edema will be loss when the patient urinate, but worst
when the patient do some activities. The patient tell that she often feels dizzeness and
tired. Now she is pregnant (5 months). Pasien said that she usually feel hungry, thirsty
often mixturia. and Patien also said she that on her genitalia therere pruritus and
produce much secret.
The medical history of the patient is kidney disease since 2015, hipertension since 2015
(not controled, patien ever consume amlodipine 10mg as antihipertension agent), DM
since she was 18 years old (not controled, patien ever consume metformin as
antidiabetic agent), and skin rash since she was child.

The patient had experience one time spontaneus abortus and one time IUFD.
Family history is DM. History of allergy is none.
 PHYSICAL EXAMINATION
BP= 160/100 mmHg HR: 84 x/minute RR = 24 x/minute T : 36.2C

General Condition : looked moderete ill GCS 456

Head Icteric sclera (-), pale Skin : rash (+)
conjunctiva (+) Sore throat (-), faring hiperemi (-)
Neck JVP= R+2 cm H2O
Thorax: Cor: Ictus invisible, ictus palpable at ICS V linea mid clavicula sinistra
RHM : ICS II Linea parasternal dextra
LHM : ICS V Linea midclavicula sinistra
S1S2 single, murmur(-)
Lung: Simetris , Fremitus vocal simetris S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -

Abdomen Tenderness + - -
+ - -
- - -
Undulation (+), acites (+)
peristaltic 8 tpm. Lien and hepar are normal
Extremity Edema extremitas inferior, pitting edema (+)

Genital -
 Laboratory Findings
Hematology
Component Value Normal Range Component Value Normal range

Hb 7,6 14,0-18,0 g/dl Limphocyte% 17 25-40%

Leukocyte 20,9 4,0-10,5 ribu/ul Urad acid 6,3 2.4-5.7%

Erythrocyte 2,4 4.00-5.30 juta/ul Gran# 18 2,5-7,0 ribu/ul

Hematocrite 21 37-47 vol% Limphocyte# 1.8 1,25-4,0 ribu/ul

Thrombocyte 282 150-450 ribu/ul MID# 1.1

RDW-CV 13,6 12,1-14 %

MCV 89 75,0-96,0 f

MCH 32 28-32 pg

MCHC 36 33-37%
 Laboratory Findings
Component Value Normal Range Component Value Normal range

Random 196 <200 mg/dl Cholesterol 243 50-200 mmol/l

Glucose
SGOT 31 0-46 U/I

SGPT 39 0-45 U/I

Albumine 2.5 3.5-5.5 g/dl

Blood ureum 79 10-50 mg/dl

Creatinine 1.3 0.7-1.4 mg/dl

 Laboratory Findings
Urinalysis Urinalysis - sediment
Component Value Usual value Component Value Usual Value
Spec. Gravity 1.025 1.005-1.030 Leukocyte 6-8 0-3
PH 5.5 5.0-6.5 Erythrocyte 2-5 0-2
Ketone negative Negative
Epithel positive positive
Protein, 3+ Negative
albumin Crystal Crystal Negative
Glucose 1+ Negative amorf (+)
Others Negative Negative
Bilirubin Negative Negative
Blood Negative Negative
Nitrite Negative Negative
Urobilinogen 0.1 0.1-1.0
leukocytes Negative
POMR
 CUE AND CLUE Problem Idx PDx PTx PMo Ped
List
1. D/ 25 yo I. Edema I. Nephroti - Loop dieretic : Urin Diet high
Ax anasarka c furosemid 1 output protein
-weakness
-nausea Syndrom amp/ 24 h Vital
-Edem of legs e - Chana albumin sign
Physic examination 3x2 caps Clinical
BP: 160/100 sign
Pitting edema SE
Edem anasarka Urinalysi
IMT= 28
Supportiv examination s,
GDS : 196
Proteinuria +3
Cholesterol : 243
Albumine: 2.5

2. Ax
-weakness, dizzeness
Phyisic examination 1.Anemia - blood Transfusion PRC
Pale conjungtiva (+) Normo smear 250 cc/day until
Supportive examination: sitik 1. Anemia - Feces Hb=10 Obs.
Hb : 7.1 normo on smear Side
kromik pregnan effect, f
cy Vital
2. Anemia sign
ec
chronic
disease
3. Anemia
ec blood
loss
 CUE AND CLUE Problem Idx PDx PTx PMo Ped
List
3. AX Hypertensio Anti- Vital Limit salt intake
-Dizzeness n grade II hipertension sign <2g/day
-Stiff Neck ec Metildopa Clinical
-G3P1A1
pregnancy 2x250mg sign
Phyisic examination
BP: 160/100

4. Ax
- Polifagi
- Poliuri
- Polidipsi Diet low
- History of DM since DM type 1 Insulin therapy Obs.TTV glucose
18 years old Obs.GDS
Phyisical examination /
Skin hiperpigmentasi
Ulkus
Scars (+)

Support examination
GDS 196
Thank you