Morning Report

September, 18th 2013

Summary of Data Base

Mrs. Nurdiyati/ 38 y.o Chief complain: Shortness of breath Patient suffered from shortness of breath since 1 day before admission. It didnt

relieved by resting, but slightly relieved by half sitting position. Shortness of breath
intermittently since 1 week before admission. She couldnt walk more than 15 meters. She often wake up at the night because shortness of breath. She sleep with 3 pillow. Previously she had cough 1 weeks before admission, with whitish sputum, but she didnt took any medication. She also complain about poignant at upper middle abdomen. Before that she was has a nefrostomy in left kidney about 10 years ago because of infection and kidney stone. According to patient she was consumed bodrex and promag almost every day about 3 years. She was diagnosed has kidney failure and got hemodialysis treatment since 3 month ago routine every week. Other illness: HT (+), DM (-) History of family illness: HT (-), DM (-)

Patients Identity
Name Sex Age Occupation Hospitalized since : Mrs. N : Female : 38 y.o : Housewife : September, 18th 2013

Physical Examination
BP = 160/100 mmHg Head HR = 84 bpm, Pale conjunctive (+) RR =24 tpm GCS 4-5-6 T : 37,2C BMI: 25 g/m2 General appearance looked mild ill

Neck
Chest Heart:

JVP (-)
S1, S2 single, murmur (-)

Lung:

Symmetric, FV ( ), Rh ( - - ), Wh (-) - + + shifting dullness (+), Undulation (+), hepar unpalpable, lien unpalpable, mass unpalpable Pitting edema on leg

Abdomen Extremities

Laboratory Result
Hb Leu 8,5 g/dl 7,8

Eryt
Hematokrit SGOT SGPT

3,02 millions/ul
26,2 16 20

Ureum
Creatinin GDS Kolesterol Total

167
17,7 114 208

PROBLEM LIST
1. CKD

2. Hypertension grade II

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/53 yo Anamnesa -SOB -Dyspnoe on effort -PND -Diagnosed with renal disease since 5 Month before admission -Diagnosed with HT since 1 year ago Cough 1 week Physical Examination -BP = 160/100 mmHg -RR = 24 tpm -Pale conjunctiva (+) -Rh (+) -Leg swelling (+) -Hb 8,4 Ur/Cr 167/17,7 eGFR 5,4 Sat 02 : 98 CXR : Cardiomegaly

1. SOB (post) 1.1 CKD st V 1.2 HF st C FC III

CXR BGA

O2 2 lpm NC Subj Bed rest RR Semifowler position Hemodialize elective Furosemid 2 x 40 mg

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/38 yo Anamnesa -Diagnosed with renal disease since 5 month before admission -Diagnosed with HT since 1 year ago
Physical Examination -BP = 160/100 mmHg -RR = 24 tpm -Pale conjunctiva (+) -Rh (+) -Leg swelling (+) -Hb 8,5 Ur/Cr 167/17,7 eGFR 5,4

2. CKD st V

2.1. HT Urinalysis nephroscleros is

low salt < 2 gr/day, protein 0.6-0.8 gr/kgBW/day Inj. Furosemide as above HD elective

Subj Lab result

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

3. Female/38 yo Hypertension Anamnesa : -Hypertension since st II 1 years ago, and took any drugs -Sefalgia

3.1 Essential hypertension 3.2 Secondary hypertension 3.2.1 Atherosclerosi s

-Diet low salt < 2g/d -Furosemide as above -kaptopril 3 x 12,5 mg

BP

Physical Examination : -BP: 160/100

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/38 yo Productive cough since 1 week -Ronkhi + in basal lung -CXR: Cardiomegaly

6. Lung Infection

6.1 Pneumonia

Ceftriaxone 2 x 1 gr

Subj RR Rh CXR 7 days after tx

TERIMA KASIH