MORNING REPORT

Wednesday, March 8th 2017

COASS IN CHARGE :
Kharisma Ridho
Yosef
Ara

Supervisor : dr. Niniek Budiarti, Sp.PD-KPTI

 SUMMARY OF DATA BASE
Mr. A /53 yo/W.27
Anamnesis: Heteroanamnesis
Chief complaint: nausea and vomiting
History of presenting illness:
Patient complained about nausea and vomiting 7 days ago and got worsen 3 days
ago. He felt nausea every time he eat, the vomit contain fluid and food without blood.
Patient said he feel weakness when he do daily activity. He also complained the decrease of
body mass about 20 kilos.
The patient was reffered from RSUD Lawang to get hemodialysis and got diagnosed
renal failure. He also had hypertension since 5 years ago. Patient said he never control to
the doctor and never consume anti hypertension drug.
SUMMARY OF DATA BASE cont..
Past medical history :
History of hospitalized in RSUD Lawang 10 days ago because nausea,
vomiting and weakness then he diagnosed renal failure
Social history :
Patient is a driver and often consume carbonated drink. Patient
married. Patient was a smoker, but now he is quit smoking. No
history of drinking alcohol.
Family history : the family had a history of renal failure, his brother
died because of renal failure, hypertension and diabetes in family.
Review of System : no complaints about passing Urinate and stool
PHYSICAL EXAMINATION
General appearance : looked moderately ill GCS 456 looked normoweight
BP : 180/100 HR 102 bpm regular RR : 18 tpm Tax : 36,5 0C
mmHg

Head Conjunctiva pale (+), icteric sclera (-), eye: light refleks (+)

Neck JVP R+0cm H2O at 30, limphnode enlargement (-)

Thorax : Cor Ictus visible and palpable at ICS V MCL sinistra
LHM~ ictus RHM: SL D
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 and traube’s space was
tympani, hepar lien enlargement (-), epigastrium tenderness (-)
Extremities Warm acral
Pitting oedema -/-
-/-
 Laboratory finding
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 8,30 11.4 – 15.1 g/dL Natrium 134 136 – 145
mmol/L
Leucocyte 9.090 4,300-10,300/µL Kalium 5,72 3,5 – 5,0
mmol/L
Hematocrit 23,00 40 – 47 % Chloride 112 98 – 106
mmol/L
Thrombocyte 205.000 142.000-424.000/µL Ureum 353,80 16.6-48.5 mg/dl

Eos/Bas/Neu/Ly 0,9/0,5/78/15, 0-4/0-1/51-67/25- Kreatinin 19,31 <1.2

mp/Mono 1/5,5 33/2-5 % eGFR 4,71 mL/min/1,73m2

MCV 74,70 80 – 93 fl Kalsium 7,0 7,6 – 11,0

MCH 26,90 27 – 31 pg Phospor 6,2 2,7 – 4,5
MCHC 36,10 32 – 36 g/dL
 CUE AND CLUE PL Idx PDx PTx PMo P edu

Mr A/53 y.o/ W27 1. CKD stage V newly 1.1 hypertension HbsAg, Bed rest, IV Plug Subjective Education
Anx : diagnosed nephrosclerosis Anti HCV O2 2-4 lpm NC Vital sign about
Nausea and vomiting 7 days 1.2 USG disease
ago and got worsen 3 days ago. abdomen Diet renal 1700
He feel weakness when he do kcal/day, RG <2gr/day,
daily activity protein 0,6-0,8 gram
History of HT since 5 years ago /kgweight/day,
Decrease of body mass about HD elective
20 kilos.
Consume carbonated drink

PE:
BP 180/100 mmHg
Conjunctiva anemis (+)

Lab:
Hb : 8,30
Ur 353,80 mg/dl
Cr 19,31 mg/dl
BUN: 165,32
eGFR: 4,71
 CUE AND CLUE PL Idx PDx PTx PMo P edu

Mr A/53 y.o/ W27 2. Hiperkalemia 2.1 decrease of renal Bed rest, IV Plug Subjective Education
Anx : excretion O2 2-4 lpm NC Vital sign about
Nausea and vomiting 7 days disease
ago and got worsen 3 days ago. Diet renal 1700
kcal/day, RG <2gr/day,
PE: protein 0,6-0,8 gram
/kgweight/day,
Lab: HD elective
K: 5,72 mmol/L Kalitake 3x5gr
 CUE AND CLUE PL Idx PDx PTx PMo P edu

Mr A/53 y.o/ W27 3. 3.1 dt no 1 CaCO3 3 x 5 mg Subjective Education

Hiperfosfatemia+hipo Vital sign about
Lab: calsemia disease
Ca : 8,0 mg/dL
Phospor ; 7,1 mg/dL
 CUE AND CLUE PL Idx PDx PTx PMo P edu

Mr A/53 y.o/ W27 4.. Asymptomatic 4.1 lower UTI USG Ciprofloxacin 2 x 200 Subjective Education
Anx : bacteriuri 4.2 Upper UTI Abdomen mg iv Vital sign about
Nausea and vomiting 7 days disease
ago and got worsen 3 days ago.
He feel weakness when he do
daily activity
History of HT since 5 years ago
Decrease of body mass about
20 kilos.
Consume carbonated drink

PE:
BP 180/100 mmHg
Conjunctiva anemis (+)

urinalisis:
Eritrosit: 330,3/LPB
Lekosit :2+
Bakteri : 44,2/µL
 CUE AND CLUE PL IDx PDx PTx Pmo P edu

Mr A/53 y.o/ W27 5. Anemia 5.1 def EPO SI S, VS, Disease,

Renal 5.2 decrease of TIBC PRC transfusion 1 CBC/3 days treatment,
Anamnesa rbc life span pack/day until Hb prognosis
Weakness and fatigue when doing >10 g/dl
daily activity
Plan to give
Physical Examination erytopoietin
Pale conjunctiva (+)

Lab:
Hb 8,30 mg/dl
MCV 74,70
MCH 26,90
 CUE AND CLUE PL Idx PDx PTx PMo P edu

Mr A/53 y.o/ W27 6. Hypertension 6.1 Secondary Fundusc Amlodipin 1 x 10 mg S, VS Educate

stage II opy Valsartan 1 x 80 mg about
Anamnesa 6.2 Primary disease,
History of hypertension treatment,
since 5 years ago diet low
salt
Px :
BP 180/100 mmHg
Conjungtiva anemic (+)
 CUE AND CLUE PL IDx PDx PTx Pmo P edu
Mr A/53 y.o/ W27 7. Dyspepsia 7.1 uremic Inj. Metoclopramide S, VS Avoid spicy
syndrome gastropathy 3x10 mg food
Anamnesa : Inj. Lansoprazole 1 x
Nausea and vomit since 7 30 mg
days ago
Vomit contain fluid and
food, no blood.

Lab
Ur 353,80 mg/dl
Cr 19,31 mg/dl
CONDITION THIS MORNING
• TD: 160/100 mmHg
• N: 122 bpm
• RR: 20
• Tax: 36,7
• Urine output: ml