MORNING REPORT

Sunday , Oktober 7th 2018

 PATIENT IDENTITY
■ Initial : NNRA
■ Sex : Female
■ Age : 54 years old
■ Religion : Hindu
■ Ethnic : Indonesia
■ Marital Status : Married
■ Address : Jl. Gunung Agung Gg. II SB I Gg I
Dembar
■ Time of arrival : Oktober 10th 2018 at 14.01
■ RM Number : 18041658
HISTORY TAKING
Chief complaint: Nausea and vomitting
Present history:
■Patient came to emergency department of
Sanglah Hospital complained about his nausea and
vomitting since 4 days BATH. Vomit more than 10
time per days. The volume of vomiting is about 2-3
spoon every vomit. The vomit contains food that
was eaten before. Patient had drugs for the nausea,
but the nausea not disappear
■Patient had low intake due to nausea
■ Patient also complain about weakness of
her body since 6 days BATH. Patient cannot
do daily activity due to weakness of her
body.
Past Illness History
■Patient was diagnosed with diabetes mellitus since 3
years ago and got insulin (novorapid 3 x 16 unit)
■Patient was diagnosed with hypertension since 3
years ago
Family History
■ There are no family members had a same
complain. There are no systemic disease in her
family.
Social history:
■ She is a housewife. She had no history about
smoking or drinking alcohol.
PHYSICAL EXAMINATION
Present State
General appearance : Mildly ill
Level of consciousness : Compos mentis E4V5M6
BP : 170/90 mmHg
PR : 96 x/min, regular, strong pulse
RR : 16 x/min, regular
Tax : 37 ºC
VAS : 0/10
Saturation : 98 % in room air
General State
■ Eyes : conjunctiva anemic (-/-); sclera icterus (-/-), reflex
pupil (+/+), isokor, palpebral edema (-/-)
■ ENT : Tonsils T1/T1; pharyngeal hyperemia (-); lip
cyanosis (-), epistaxis (-), gums bleeding (-)
■ Neck : JVP 0 cmH2O; enlargement of regional lymph
nodes (-)
Thorax : symmetrical
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis not palpable]
Percussion :
UB : ICS II Sinistra
LB : AAL ICS III Sinistra
RB : PSL Dextra
Auscultation : S1 S2 normal regular, murmur (-)
Pulmo
Inspection : Symmetric
Palpation : symmetric, fokal fremitus normal
Percussion : sonor in all the lung lobes
Auscultation : vesicular + + , Rh - - , Wh
- -

+ + - - - -
Abdomen :
■ Inspection : Distention (-), scar (-)
■ Auscultation : Bowel sounds (+) normal
■ Percussion : Timpani (+)
■ Palpation : liver and spleen not palpable
■ Extremities : Warm, oedema (-/-)
COMPLETE BLOOD COUNT
Parameter Result Unit Remarks Reference Range

WBC 12.33 103/μL high 4.1 – 11,00

-Ne% 90.77 % high 47,00 – 80,00

-Ly% 7.07 % low 13,0 – 40,0

-Mo% 1.72 % low 2,00 – 11,00

-Eo% 0.04 % 0,00 – 5,00

-Ba% 0.40 % 0,0 0 – 2,00

-Ne# 11.19 103/μL high 2.50 – 7.50

-Ly# 0.87 103/μL low 1.00-4.00

-Mo# 0.21 103/μL 0.10-1.20

-Eo# 0.01 103/μL 0.00-0.50

-Ba# 0.05 103/μL 0.05

COMPLETE BLOOD COUNT
RBC 3.56 106/μL Low 4,50 – 5,90

HGB 10.00 g/dL Low 13,50 – 17,50

HCT 31.29 % Low 41,00 – 53,00

MCV 87.91 fL 80,00 – 100,00

MCH 27.32 pg 26,00 – 34,00

MCHC 32.01 g/dL 31,00 – 36,00

RDW 12.21 % 11.6-14.8

PLT 237.9 103/μL 150,0 – 440,0

 Blood Chemistry
Parameter Result Unit Remarks Reference range

SGOT 10.5 U/L Low 11.00 - 27.00

SGPT 9.60 U/L Low 11.00 - 34.00
BUN 72.50 mg/dL High 8.00 - 23.00
Creatinine 9.23 mg/dL High 0,50-0,90
BS acak 157 mg/dL High 70-140

Albumin 3.50 g/dL 3.40-4.80

HbA1c 6.2 % High 4.8-5.9

Blood Gas Analysis & Electrolite
Parameter Result Unit Remarks Reference
range
pH 7.31 low 7.35-7.45

pCO2 29.6 mmHg low 35.00-45.00

pO2 122.70 mmHg high 80.00-100.00

HCO3- 14.50 mmol/L low 22.00-26.00

Natrium (Na) 146 mmol/L high 136-145

Kalium (K) 5.32 mmol/L high 3.50-5.10

Chloride (Cl) 93 mmol/L Low 96-108

urinalysis
Parameter Result Unit Remarks Reference
range
Kekeruhan Jernih
pH 6.00 4.5-8
Leukosit Negatif Leuco/uL Negatif
Nitrit Negatif Mg/dL negatif
protein (4+) OVER mg/dL negatif
Glukosa (2+) 200 mg/dL negatif
Keton (1+) mg/dL negatif
Darah (1+) ery/uL negatif
Urobilinogen Normal mg/dL Normal
Bilirubin Negatif mg/dL Negatif
Warna Light yellow p.Yellow-yellow
Leukosit 2 /LPB
sedimen
Eritrosit 3 /LPB
sedimen
Gepeng 2 /LPB
IMAGING RESULT
Cor : besar dan bentuk
kesan normal. Kalsifikasi
aortic knob (+)
Pulmo : tak tampak
infiltrat/nodul. Corakan
bronchovaskuler meningkat
Sinus pleura kanan kiri
tajam
Diaphragma kanan kiri
normal `
Tulang-tulang : tidak tampak
kelainan
EKG
ASSESSMENT
1 CKD stage V ec suspect DKD
- gastropathy uremicum
- anemia normocromic normositer
- Hypertension Stage II
3. DM Type II
PLANNING
■ IVFD NaCl 0,9% 8tpm
■ O2 2 lpm nasal canule
■ Diet CKD 35 kkal/kgBB/hari + 0,8 gram protein/kgBB/hari
■ Domperidone 10 mg every 8 hours PO
■ Asam folat 2 mg every 12 hours PO
■ Irbesartan 300 mg every 24 hours PO
■ Novorapid 8 unit every 8 hours subcutan before eat
■ HD elective
Planning Diagnostic
■ Urinalysis
■ USG abdomen

Monitoring
■ Vital sign
■ Complain
■ Urine output
■ BS 2 hours Post prandial every 24 hours
THANK YOU