MORNING REPORT

Tuesday, August 8th 2017

COASS IN CHARGE :
Anindya Paramitha
Vanni Putri Pratiwi
Arief Fadillah
Merika Soraya
Faras Maysifa Hasan
Ika Wahyuni P
Septha Rully Dwi P.
Safira Rosalina
Supervisor : dr. Rulli Rosandi, Sp.PD
 SUMMARY OF DATA BASE
Mr. R/ 35 yo/Ward 25 Bed 2.2
HISTORY TAKING : autoanamnesis
CHIEF COMPLAINT : Shortness of Breath
HISTORY OF PRESENT ILLNESS :
Patient has been feeling shortness of breath since 2 weeks ago. SOB
was getting heavier since 3 days ago and aggreviated on doing
activities and relieved on rest. Before SOB patient complaint
cough since 2 weeks ago with white thick sputum.
Patient also had a fever that occurred intermittently accompanied
with shivering since 2 weeks ago. He took paracetamol from
primary health care.
Patient slept using 2 pillows and was awaken due to sob.
He had smoked since 15 years ago (2 packs/ day/ each contains 20
cigarettes) and stopped 5 years ago.
He had been drinking soft drinks every day since 15 years ago
and stopped 2 weeks ago due to cough.
SUMMARY OF DATA BASE
PAST MEDICAL HISTORY :

He has no history of DM and/or hypertension.

SOCIAL HISTORY :-

FAMILY HISTORY :

-
 PHYSICAL EXAMINATION
General appearance : looked moderate ill GCS 456

BP : HR 69 bpm regular RR : 20x/mnt Tax : 37 0C

Pre HD 240/110
Post HD 130/100

Head Conjunctiva pale (+), icteric sclera (-), eye: light reflex (+)
Neck JVP R+3 cm H20
Thorax : Cor Ictus invisible, palpable in ICS 5 MCL Sin
S1, S2 single, murmur (-), gallop (-)
Pulmo Symmetric , Percution sonor sonor Rh - - wheezing - -
sonor sonor -- --
sonor sonor -- --

Abdomen flat, bowel sound normal, soefl, liver span 8 cm, painless and traubes
space was tympani, shifting dullnes (-),
Extremities Pale, warm acral
Pitting oedema +/-
 Laboratory finding
Laboratory Result Normal Value Laboratory Result Normal Value
Fe 124 53-167 g/dL
Hb 6,10 11.4 15.1 g/dL
TIBC 225 300-400 g/dL
Natrium
RBC 2,01 4,0-5,5 /L 134 136 145 mmol/L

WBC 65800 4,300-10,300/L Kalium 3,86 3,5 5,0 mmol/L

Hct 17,20% 40 47 % Chloride 103 98 106 mmol/L

Ureum
PLT 149.000 142.000-424.000/L 154,60 16.6-48.5 mg/dl

creatinine
19,33 <1.2 mg/dl
Eos/Bas/Neu/Lymp/ 7,8/0,0/57,1/28,1/ 0-4/0-1/51-67/25-33/2-5
Mono 7 % eGFR 4,19 >90mL/min/1,73m2

MCV 85,60 80 93 fl
Uric Acid 7,5 3,4-7,0 mg/dL
MCH 30,30 27 31 pg

Ca 8,9 7,6-11 mg/dL

Albumin 3,51 3,5-5,5 g/dL
Phospor 5,6 2,7-4,5 mg/dL

RBS 161 <200 mg/dl

 POMR
Clue and cue
Problem
Initial Dx
list

Male/59 yo/ W 22 1. HT 1.1 Diet low salt < 2 gr/day Pmo:

Bed 6.2 urgency secondary Soft diet 1700 kcal/day Subjective
hypertension PO: Vital sign
Ax: - Amlodipin 1 x 10mg
Has been 1.2 primary - Valsartan 1 x 80 mg Ped :
diagnosed as CKD hypertension - Bisoprolol 1 x 2,5 mg Explained
since 4 months on recent
routine HD condition,
2x/week and management,
hypertension and prognosis
since then Salt and fluid
restriction
PE :
BP:
Pre HD 240/110
Post HD 130/100
 POMR
Clue and cue
Problem list Initial Dx

Male/59 yo/ W 22 2. CKD st.5 2.1 HT Diet : PMo:

Bed 6.2 on routine nephroscler Renal diet Subjective
HD osis 1700 kcal/day, Vital sign
Ax: 2.2 NSAID- Low sodium
Has been diagnosed as induced intake Ped:
CKD since 4 months on nephropathy <2gram/day Explained
routine HD 2x/week protein 1 recent
and hypertension
since then
gr/kgBW/ day condition,
management,
PE : Negative fluid and prognosis
BP: 240/110 mmHg balance 500 Salt and fluid
Anemic conjunctiva cc/day restriction
+/+ CaCO3 3 x 500 mg
Edema on left arm HD twice a week
LF :
Hb :6,10 g/dL
Ur : 154,6 mg/dL
Cr : 19,33 mg/dL
eGFR : 4,19 ml/min
P : 5,6 mg/dl
 POMR

Clue and cue Problem list Initial Dx

Male/59 yo/ W 22 4. Diet : Pmo:

Bed 6.2 Hyperuricae protein 0,6-0,8 Subjective
mia gr/kgBW/ day Vital sign
Ax:
No history of joint PO Allopurinol Ped :
pain 100mg/ 48 hours Explained
recent
PE :
-
condition,
management,
LF : and prognosis
Uric Acid : 7,5 High uric acid
contained foods
restriction
 POMR

Clue and cue Problem list Initial Dx

Male/59 yo/ W 22 5. Anemia 5.1 EPO PRC Transfusion Pmo:

Bed 6.2 Normochrom deficiency 2 packs durante Subjective
ic 5.2 Decrease HD with target : Vital sign
Ax : Normocyter RBC survival Hb >8g/dL
Ped :
PE : Explained
Pale conjuctiva recent
condition,
LF : management,
Hb : 6,20 g/dL and prognosis
MCV : 85,6 fl
MCH : 30,30 pg
Condition this morning
GCS 456
BP 180/100 mmHg
HR 69 bpm
RR 20 tpm
SpO2 99% on room air
Tax 36,3oC