Morning Report

April 30
th
, 2014

Doctor in charge:
Dr Haryati Sp. P
Patients Identity

Name : Mrs. E
Sex : Female
Age : 43 yo
Occupation : Housewife
Hospitalised since : April 29
th
, 2014
Summary of Data Base
Mrs.E / 43 yo /Female (Autoanamnesys)
Chief Complaint : Hard to breath
Patient felt herself was hard to breath since 2 weeks ago. It was felt like
something compressed her chest. The patient also complained having dry
cough since a week ago, but it has been decreased recently. Her body had
swollen since half month ago, gradually from her stomach, waist, both of arms,
legs and chest. She had been unable to walk since 2 months ago, unless she
got help from other people. She complained that both of her eyes gotten blurry
since 5 months ago. She also complain about her urine become brownish like
tea, and unsatisfied when she urinated. Last time she defecated was 3 days
ago, with watery consistency. Her appetite was decreased. Her sleep was
disturbed. She also felt nausea and had vomited twice since yesterday
morning.
History of last illness: HT (+) 2 months ago
DM (+) 5 years ago. Amputated left pinky finger half year ago.
History of Family illness: -

Physical Examination

General appearance Looked moderately ill, Conscious, GCS : 4 5 6
Blood Pressure 160/100 mmHg
Pulse Rate 101 bpm regular, strong
Respiration rate 24 Tpm, shallow
Temp 36,6
0
C
Head Pale conjunctiva (+/+), Jaundice sclera (-/-), decreased visual acuity (+/+), Edema
palpebra (+/+), Diplopia (+), discharge (+/-)
Neck JVP= R + 8 H2O , Lympatic node swelling (-)
Chest Heart Inspection : ictus invisible
Palpation : palpable in MCS ICS V
Percution : Right-Upper : ICS II LPS (D), Right-lower ; ICS V LPS (D). Left-upper : ICS II
LPS (S). Left-lower: ICS V LMC (S)
Auscultation : S1 > S2 single, murmur (-) gallop (-)
Lung Inspection : Simetric, barrel chest (-)
Palpation : FV simetric
Percution : Auscultation :
S | S V | V
S | S V | V
S | S V | V
Wheezing (-), Ronchi (-)
Abdomen Dullness, Liver / Spleen / Mass hard to evaluate
D | D + | + | +
D | D + | + | +
D | D + | + | +
Extremities Superior D & S : Edema (+), Pain (-), Weakness (-)
Inferior D & S : Edema (+), Pain (-), Weakness (+)

Laboratory Result 27/4/2014
Items Result Normal Value Unit
Hematology
Hemoglobine 9.6 12.00 - 16.00 g/dl
Leukocyte 8.0 4.0 10.5 thousand/ul
Eritrocyte 3.55 3.90 5.50 million/ul
Hematocrit 29.3 37.00 47.00 Vol%
Trombocyte 458 150 450 Ribu/ul
RDW-CV 15.7 11.5-14.7 %
MCV 82.8 80.0 97.0 Fl
MCH 27.0 27.0 32.0 Pg
MCHC 32.7 32.0 38.0 %

Items Result Normal Value Unit
Gran% 70.1 50,0-70,0 %
Limfosit% 20.4 25,0-40,0 %
MID% 9.5 4,0-11,0 %
Limfosit# 1.6 1,25-4,0 thousand/ul
Gran# 5.6 2,5-7,00 Thousand/ul
MID# 0.8 thousand/ul
Continue
Items Result Normal Value Unit
Random blood glucose 94 <200 mg/dl
Total Bilirubin 0.39 0,20-1,20 mg/dl
Bilirubin Direct 0.22 0-0,40 mg/dl
Bilirubin Indirect 0.17 0,20-0,60 mg/dl
SGOT 26 0-46 U/I
SGPT 16 0-45 U/I
Albumin 3.0 3,5-5,5 g/dl
Ureum 128 10-50 mg/dL
Creatinin 9.2 0.7-1.4 mg/dL
Natrium 140 135-146 mmol/l
Kalium 4.0 3.4-5.4 mmol/l
Chloride 105.5 95-100 mmol/l

CUE AND CLUE PL IDx PDx PTx PMo
Female/43 yo

Anamnesis
- Hard to breath
-History of cough
-Swollen body
-Unable to walk
-Blurry vision
- Unsatisfied urinating
-Brownish tea like
urine
-Watery faeces
-Nausea and vomitting


Physical Examination
BP : 160/100 mmhg
T: 36,6C
HR: 101 bpm
RR: 24 tpm
Edema at abdomen, leg
and her arms
Abdominal pain at all regio
of stomach

Laboratory:
Hb : 9.6
Eritrocyte : 3.55
Hematocrite : 29.3
Trombocyte : 458
RDW-CV : 15.7
Limfosit% : 20.4
Albumin : 3.0
Ureum: 128
Creatinin: 9.2

EKG : Sinus Rhytim
100bpm
LFG 9,96 mL/minute

hipohyxia

Swollen
Body

Anemia
Normochro
mic
Normocytic

Blurry
Vision


Edema
generalisata
e\c CKD gr V
with
Retinopathy
diabetic and
Hypertension
Stage 2

1. Blood film

2. Urine

3. Ureum-
Creatinin

4. Abdomen
USG and
Urology

5. Random
Blood
Sugar

6. Fasting
Blood
Sugar

7. Anti HCV,
Anti HAV,
Anti
HbsAg

Pharmacologic
- Inj. Lasix 2 x I
- Inj Ranitidine 2 x I
-Inj. Metoclopramide 3 x I
-Inj. Scopamin 3 x I
-Inj. Interpril 10g 1 x I


Non-pharmacologic
-Bed rest
-Enough food and balanced
calories
1QA


Planning Education
Take medication as prescribed
Education for family and patient that the sickness need
further investigation
Be patient and cooperate
Thank you