Morning Report

Wednesday, April 30th 2015

Coass in charge
Wahyu F

Supervisor: dr. Putu Moda A, Sp.PD

 SUMMARY OF DATA BASE
Mrs H., 40 yo, W. 28
Autonamnesa and heteroanamnesa (patient’s husband)
Chief complain:
Family Hystory :
Social History :
 PHYSICAL EXAMINATION
General appearance looked severelyly ill GCS : 456
Looks normoweight
BP : 150/60 mmHg PR = 84 bpm regular strong RR = 22 tpm Tax : 35,8 0C
Head Conjuctiva Anemic (-)
Sclera Icteric (-)
Neck JVP R + 0 cm H20, 300 position Lnn. Enlargement (-)
Thorax Ictus invisible & palpable at ICS V MCL S
Double line at thorax dextra
Heart RHM ~PSL D, LHM ~ ictus
S1 S2 single regular, murmur (–), gallop –
Lung Symetric Stem fremitus D=S Sonor + + v v Rh - - Wh - -
++ v v - - - -

++ v v - - - -

Abdomen Flat, Bowel Sound + N, liver span 10 cm,traube space tympani , Shifting dullness (-)

Extremities Edema + + anemic - - Warm acral + +

+ + - - ++
CRT < 2 second, Turgor < 2 second
 LABORATORY FINDINGS
29 April 2015/15.07
Lab Value Lab Value
Leucocyte 15.610 4.000-11.000/µL Na 128  126 136-145mmol/l
Diff Count 0.1/0.2/94. 0-4/0-1/51-67/25-
K 6,91  5,24 3,5-5,0 mmol/l
8/1.8/3.1 33/2-5 %
Haemoglobin 4.60 11-16,5 g/dL Cl 108  76 98-106 mmol/l
MCV 89,40 80-93 fl Ca 7,4 7,6 - 11,9 mg/dL
MCH 28,6 27-31pg Phospor 5,5 2,7 – 4,5 mg/dL
Hematocrit 14,3 38-42 % Ureum 205,20 16,6-48,5 mg/dL

Thrombocyte 82.000 142-424x103/µL Creatinin 10,20 < 1,2 mg/dL

SGOT/AST 76 0-41U/L BUN/cr
SGPT/ALT 388 0-41U/L RBS 54 < 200 mg/dL

Albumin 3,27 3.5 – 5.5 gr/dL PTT 12,40 second 9,4 – 11,3 second

APTT 29 second 0,8 – 1,3 second

 BLOOD GAS ANALYSIS
BGA Value Normal Value

PH 7.22 7,35-7,45
PCO2 18.0 35-45 mmHg
PO2 164.1 80-100 mmHg
HCO3 7.4 21-28 mmol/L
Base Excess -20.5 -3 until +3 mmol/L
O2 saturation 97.1 > 95%
Conclusion Metabolic Acidosis partially compensated with respiratory
alkalosis
 URINALYSIS
Lab Value Lab Value
Clear Clear 10 x
Color Yellow Yellow Epitel 3.3 ≤ 1lpf
pH 7.0 4,5 - 8,0 Cilinder - Lpf

MW 1.025 1,010 – 1,015 Hialin - ≤2

Glucose - Negative Granular - Negative

Protein 3+ Negative 40 x

Keton - Negative Erythrocyte 4.3 ≤ 3 hpf

Bilirubin - Negative Leucocyte 7,7 ≤ 5 hpf
Urobilinogen - Negative Cristal Ca Oxalat + hpf
Nitrit - Negative Bacteria 246 x 103 ≤ 93 x 103/mL
Leucocyte 2+ Negative
Blood 3+ Negative
 ECG

 Sinus rhythm, Heart rate 100 bpm

 Frontal Axis : Normal
 Horizontal Axis : Normal
 PR interval : 0,14”
 QRS complex : 0,10”
 QT interval : 0,40”

Conclusion : Sinus rhythm, with HR 100 bpm and T tall

 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
1. Hypercalemia Kalitake 3x15 Pmo:
dt CKD stage gr Subjective
V Vital sign

P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
2. Anemia 2.1 Renal PRC Pmo:
Gravis NN Anemia tranfusion 2 Subjective
bags durante Vital sign
HD
P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
3. HT stage II 3.1 primary PO Pmo:
3.2 secondary Clonidine Subjective
3x0,15 mg Vital sign
Amlodipine
1x10mg P.Edu:
ISDN 3x5mg Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
4. CKD stage V 4.1 HT O2 2-4 Pmo:
on HD Nephroscler L/minutes Subjective
(moderate osis HD 4 hours Vital sign
HD) 4.2 NSAID UF 2,5 L
nephropathy Qb 180-200 P.Edu:
Qd 500 Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
5. Hypoglicemia 5.1 Low Inj. D40% IV Pmo:
intake if RBG < 100 Subjective
Vital sign
IVFD D5%
lifeline P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
6. Dyspepsia 6.1 Uremic Inj. Pmo:
Syndrome gastropathy Metoclopram Subjective
6.2 PUD ide 3x10mg Vital sign
iv
P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
7. 7.1 Catheter Hemostat Pmo:
Psuedoaneuri insertion/ 1x1 Subjective
sm D/S access Vital sign
durante HD Cefoperzone
1 gram  P.Edu:
CVC Disease
prophylaxis Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
8. Increased 8.1 Reactive HBsAg Wait the Pmo:
transaminase 8.2 Hepatitis Anti HcV result of Subjective
viral HBsAg Vital sign
infection Anti HcV
P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
9. Metabolic Pmo:
Acidosis Subjective
partially Vital sign
compensated
with respiratory P.Edu:
alkalosis Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
10. Pmo:
Hyponatremia Subjective
hypoosmolar Vital sign
hypovolemia
dt dilutional P.Edu:
Disease
Therapy
Prognosis
 P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
11. 11.1 Urinary Pmo:
Leucocytosis Tract Subjective
Infection Vital sign

P.Edu:
Disease
Therapy
Prognosis
THANK YOU….