MORNING REPORT

CASE
June 19
th
,
2014

PATIENTS IDENTITY
Name : KS
Age : 60 yo
Gender : Male
Ethnicity : Balinese
Religion : Hindu
Address : JL Pulau Singkep
MR : 14036830


ANAMNESIS
Chief complain :
nausea
Present history :
Patient came with chief complain of nausea
since 7 days BATH. It worsened day by day
and there were no factor that could relieve
this symptom
Patient also complained about vomitting
which were started since 7 days BATH. He
vomitted 3 times per day and volume of each
vomit was about glass of aqua. The
contain of the vomit was food which are
consumed by the patient beforehand.





He coughed since 7 days BATH.
Productive cough with yellowish phlegm.
There was no blood in the phlegm.
He also complained about swollen in his
leg.
The patient difficult to urinate since 4 days
BATH and the volume of urin decreased
by day. 1 day BATH, patient couldnt
urinate.
breathlessness since 2 days BATH, and
worsening since yesterday. Symptom felt
better if the patient sit up and lean
forward. Wheezing was denied.
stool turned black since 3 days BATH. The
consistency was soft, frequency was 2-3
times a day and it accompanied by pain in
lower abdomen. It was about half of glass on
each defecation. On the admissions day,
there was no blacky stool.
4 days BATH, the patient also had nausea
and vomitted a few times, approximately
glass each, containing food & saliva. But
stopped since 1 day BATH. Blood (-)
cough (-), fever (-)
Medication history :
Two days ago, the patient came to Bakti
Rahayu with a chief complaint of blacky
stool. The patient received :
Mixtat 20 IU, Acetosal 1x , biosanbe
1x1, lasix 1 amp, transf. PRC 1 kolf
The patient was then referred to Sanglah
hospital because of swollen body and
decrease of conciousness
Past illness history
Patient had the history of diabetes melitus
since 4 years ago and was on insulin injection
and oral medication but forget the name of the
drug.
Patient also had a history of hypertension
since 2 years ago but the family unclear of the
details of the medications.
6 month ago, patiet had a history of urinating
stones.

Family history :
None of the family member had the same
complained as the patient
History of renal abnormalities, HT, and DM
was denied

Social History :
Alcohol consumption and smoking was
denied. Jamu consumption was also denied.




PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : compos mentis
GCS : E
4
V
5
M
6
Vital Sign:
BP : 160/100 mmHg
RR : 18 x/min
PR : 88 x/min
t
ax
: 36,7C
Body weight : 84 Kg
Height : 170 cm
BMI : 29,06 kg/m
2
Eyes : conj. Pale (+/+); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-
); tongue normal; lip cyanosis (-)

Neck : JVP RP + 2 cmH
2
O;
lymph node enlargement (-)




Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis not palpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po
Inspection : Symetric
Palpation : VF N/ N
Percussion : /dull
Auscultation : vesikular + / + , Rh -/-, wh -/-

Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani
Palpation : Tenderness on palpation
(-); liver & spleen not palpable
Ballotment (-/-)



Extremities: Warm +/+; edema -/-
+/+ -/-


Complete blood count

Parameter Result Unit Remarks Reference range
WBC 7,40 10
3
/L 4,5 11,00
-Ne 90,50% 6,70 10
3
/L H 47,00 80,00
-Ly 7,1% 0,50 10
3
/L L 13,0 40,0
-Mo 2,10% 0,20 10
3
/L 2,00 10,00
-Eo 0,10% 0,00 10
3
/L 0,00 5,00
-Ba 0,20% 0,00 10
3
/L 0,0 0 2,00
RBC 2,93 10
6
/L L 4,50 5,90
HGB 9,10 g/dL L 13,50 17,50
HCT 25,40 % L 41,00 55,00
MCV 86,8 fL 80,00 100,00
MCH 31,20 pg 26,00 34,00
MCHC 36,00 g/dL 31,00 36,00
RDW 12,70 % 11,60 14,90
PLT 385,00 10
3
/L 150,0 440,0
MPV 6,70 fL 6,80 10,00
Blood chemistry panel
Parameter Result Unit Remarks Reference range
SGOT 27,75 U/L 11,00 33,00
SGPT 20,06 U/L 11,00 50,00
BUN 100,90 mg/dL H 10,00 23,00
Creatinine 13,73 mg/dL H 0,50 1,20
eGFR 6,47 ml/min
Uric Acid 10,79 mg/dL H 2,00 7,00
Random blood
glucose
321 mg/dL H 70,00 140,00
Blood Gas Analysis
Parameter Result Unit Remarks Reference range
pH 7,34 - L 7,35 7,45
pCO
2
39,00 mmHg 35,00 45,00
pO
2
73,00 mmHg L 80,00 100,00
Hct 25,00 % L 37,00 48,00
HCO
3
-
21,00 mmol/L L 22,00 26,00
TCO
2
22,20 mmol/L 24,00 30,00
BE(B) 4,40 mmol/L -2 2
SO
2
c 93,00 % --
THbc 7,80 g/dL 13,00 18,00
Natrium 100,00 mmol/L L 136,00 145,00
Kalium 3,40 mmol/L L 3,5 5,1
Urinalysis
Parameter Result Unit Remarks Reference range
pH 5,00 - 5 8
Leucocyte Neg Leu/uL +2 Negative
Nitrite Neg - neg Negative
Protein 500,00 mg/dL +4 Negative
Glucose 100,00 mg/dL +2 Normal
Ketone neg mg/dL Neg Negative
Urobilinogen norm mg/dL Neg 1 mg/dl
Bilirubin neg mg/dL neg Negative
Erytrocyte 25,00 ery/uL +5 Negative
Spesific Gravity 1,015 - 1,005 1,020
Colour p. Yel - p.yel p. yellow - yellow
SEDIMEN URINE
Leucocyte 0-1 /lp <6/lp
Erytrocyte 1-2 /lp <3/lp
Silinder Granular (+) /lp ---
Others Bactery (+) /lp ---
Ro. Thorax
Cor :
CTR 59%
Pulmo :
Perivascular haziness in
both lung
Conclusion :
Lung edema
Cardiomegaly

BOF
Radioopaque
appearance (-)

ECG
Sinus rhytm
Axis normal
HR 76 x/min
ST-T change (-
)
LVH (-)
Conc. : Normal
ASSESMENT
CKD stage V ec suspect DKD dd PNC
- DOC ec Suspect ensefalopaty uremium dd:/ hiponatremia
- Melena ec suspect gastropaty uremium
- Lung edema
- Acidosis Metabolic
- Mild anemia Normocromic Normositter on CKD
- Hyperuricemia
Hiponatremia hipoosmolar Cronic asymptomatic hypervolemic
DM type II
Suspect HHD / fc II
- Hypertension stage 2


PLANNING
Therapy
MRS
O2 4 liter per minute
IVFD NaCl 0,9% 8 dpm
Fasting
NGT with gastric cooling blood (+)
HD emergency free heparin
Pantoprazole 2x40 mg
Antasid 3 xCI
Sulcrafat 3 x CII
Drip Novorapid 4 IU/jam until BS 200
- drip novorapid 1 IU/ jam with D5%
Ramipril 1 x 5 mg
CaC03, Folic Acid and Allopurinol (postponed)
Pdx
Blood smear
SI, TIBC, Ferritin
USG Abdomen
HbA1c, Lipid Profil
Consult opthalmology

Monitoring
Vital sign
Bleeding, counciousness
Complaints
Fluid Balance
Blood sugar @ 1 hour
Blood Gas analysis post HD
Electrolyte


THANK YOU