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MORNING REPORT

Friday, July 15 th 2011


PHYSICIAN INCHARGE: IA: dr. Rifai, dr. Yuni, dr. Bagus IB: dr.Angga, dr. Didin II : dr. Fatma III: dr. C Singgih W, SpPD Moderator : dr. Gatoet Ismanu, SpPD KPTI

SUMMARY OF DATA BASE


Mr. M/15yo / w. 22 Chief complaint : vomiting
Patient suffered from vomiting since 4 days before admission, about 3 time per day or every meal, contain residual food and water, with volume glass, and the last days accompanied with coffee ground vomiting just 1 time about glass, without epigastrial pain. So, he had decrease of appetite. He also complain about swelling all of his body since 1 month ago, gradually from his feet and referred until his face. Already diagnosed with renal disease after discharge at word 27 RSSA but after that he didnt controlled routinely, because he always refuse for check his condition to the RSSA and the last medication he got furosemid, captopril, and folic acid.

Physical Examination
General appearance Blood Pressure Pulse Rate Looked midly ill, GCS 456 W: 60 kg H: 158 cm BMI:24 kg/m2 130/80 mmhg 88 bpm, strong regular

Respiration rate
T ax Head Neck Thorax Heart

24 tpm (W)
36.2C Anemic (+ ), Icteric (-), face edema, NGT + cofee ground JVP R + 0cm H2O Ictus invisible palpable in MCL S ICS V RHM sternal line D, LHM as Ictus S1 S2 single, murmur Insp: D=S Symmetric Palp: Stemfremitus D=S Perc: S S SS SS Ausc: V V rh: - - wh: - VV --VV ---

Lung After HD
Abdomen ,Extremities

Flat ,Soefl, Liver span 8 cm, troube space tympani , BS (+) N, epigastic pain (-) , meteorismus (-) Leg Oedem +, pale +, RT (-)

Laboratory finding
Lab Leucocyte Haemoglobin Value 8.100 /L 3.3 g/dl Lab Na K Value 135 4.7 Mmol / L Mmol / L

MCV
MCH
PCV Thrombocyte RBS Ureum Creatinin eGFR

81 um3
29.6 pg 9.0 % 230.000 /L 130 mg/dL 285.9 mg/dL

Cl
OT PT

107
18 15

Mmol / L
U/L U/L

Albumin

2.18

26.98 mg/dL 3.82

urinalysis
SG =1.015 Glucose (-) PH = 6.0 Protein : ( +4) Ketone (-) Ery (+3 ) Nitrite:(-) Ery : ( 10-15 )hpf Crystal (-) Bactery: ()

Leuco : (- ) ( 5-10 hpf)

ECG

ECG

Sinus rhythm, HR : 86 tpm PR interval : 0.12 QRS interval :0.08 QT interval :0.4 Frontal Axis : Normal Horizontal Axis : normal Conclusion : Sinus rhythm with HR 86 bpm,

CXray( june 23 th 2011)

CXray( june 23 th 2011)


Thorax PA, symmetric, less inspiration, bone and soft tissue normal, sinus phrenico costalis R and L sharp, hemidiaphragma R and L dome shape, trachea in the middle, Lung normal Cor: Site, shape normal size: 50% Conclusion: normal CXray

CUE AND CLUE

PROBLEM LIST

INITIAL DIAGNOSE

PLANNING DIAGNOSE

PLANNING THERAPY

PLANNING MONITORING

1.M/15 yo Ax:
Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, decrease of appetite swelling all of his. Already diagnosed with renal disease didnt controlled routinely, the last medication he got furosemid, captopril, and folic acid. Some time he also felt shortness of breath if he done a hard work, and the SOB became relived with rest.

1. CKD st 5

1.1 GNC 1.2 PNC

Renal biopsy

-. Renal diet 1700 kcal/day with protein 0.6-0.8mg/kg/day, low salt < 2 gr/day, cholesterol <300 gr/day -.Venflon -. Semi fowler position -. Negative fluid balance 500 cc/day -. Inj : Furosemid 40 mg-40 mg -0 -HD

BP, RR, urine production

PD:
RR: 24 tpm , conjungtiva anemic, edema at face, leg, extremity looks

pale Lab; Hb: 3.3, ur/cr : 285.9/ 26.98, eGFR: 3.8, albumin 2.18, proteinuria: +4, eritrocituria+3,

CUE AND CLUE

PROBLEM LIST

INITIAL DIAGNOSE

PLANNING DIAGNOSE

PLANNING THERAPY

PLANNING MONITORIN G

2 M/15 yo Ax: Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, PE: BP 130/80, PR: 88 tpm
RR: 24 tpm, conjungtiva anemia +, extremity looks pale, NGT + coffee ground

2. Upper GI bleeding

2.1 uremic gastropathy

Endoscopy

-. NGT gastric lavage Bleeding, Hb per 8 hr, 1 time negatif fluid diet. -. Bolus omeprazole 80 mg continous with drip omeperazole 8 mg/ hr until 72 hr or bleeding was stop

Lab; Hb: 3.3, MCV 81 MCH 29.6, ur/cr : 285.9/ 26.98, eGFR: 3.8,

CUE AND CLUE

PROBLEM LIST

INITIAL DIAGNOSE

PLANNING DIAGNOSE

PLANNING THERAPY

PLANNING MONITORIN G

3 M/15 yo Ax: Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, PE:
conjungtiva anemia +, extremity looks pale, NGT + coffee ground

3. Anemia Normo Normocyter

4.1 due to CKD 4.2 due to upper GI bleeding

Retyculocyte -.plan PRC tranfusion count

Hb

Lab; Hb: 3.3, MCV 81 MCH 29.6, ur/cr : 285.9/ 26.98, eGFR: 3.8,
4. M/15 yo Ax: decrease of appetite swelling all of his. Already diagnosed with renal disease didnt controlled routinely, albumin 2.18, proteinuria: +4,

4. 4.1 renal loss hypoalbumin

Protein esbach

-protein diet 0.60.8mg/kg/day, + protein ebach

Complain, albumin serum

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