Morning Report

Friday, July 6th 2018

RPI/AWA/FIN
No Name Gender,Age Working Diagnosis
1. IFJ Boy , Hypertensive crisis+ Glomerulonephritis
12 years 6 Acute Pasca Streptococcus + Obesity
month
1
New Patient in Emergency Room at 02.00 a.m IFJ, boy, 12 Years 6 month,
address: Mancang, Blang Kejeren
BW : 70 Kg BL : 160 cm, Ideal weight : 48 Kg
W/A : 162% H/A: 105% W/H : 152% BMI : 27,3 (P>95th)

Chief complaint : Seizure

History of present illness :
• Seizure was occurred 1 day prior to consult. Seizure was discribed as
shaking all over the body and upward rolling eyes with duration ±10
minutes, 2x at home,1x at clinic and 1x at hospital. Stesolid was given in the
clinic and hospital. After seizure, the patient was conscious. In our
emergency room, there was no seizure.
• He had high blood pressure that was measured, with the highest blood
pressure 200 mmhg.
• Dark coloured urine like coca-cola was noted since 1 day prior to consut.
• No history of painful urination or difficult to urinate.
• Swelling of the face, hand , and feet were noted when the patient at ER.
• 6 weeks prior to consult, the patient had multiple pustul lesion with
erythematous around that itchy on body and extrimities. The lesions are
already dry.
• No history of fever, cough, sore throat.

History of previous illness :

• Patient was referred from Blang Kejeren Hospital with diagnosis of urgency
hypertention + acute kidney injury stadium risk +
dd/ - Acute Glomerulonephritis + Obesity
- Nephrotic Syndrome

History of previous medication:

• Ampicillin injection 1 gram/6 hours, furosemide injection 70 mg/12 hours,
captopril 2 x 25 mg, nifedipine 10 mg, IVFD D5%
Physical Examination
General status :
Alertness : Compos Mentis, Temperature : 36,60C
dyspnoe (-), cyanosis (-), edema (+), icteric (-), anemic (-)

Localized status:
Head: Facial swelling (+)
Eye : Light reflexes (+/+), isochoric pupil, Ø3mm/3mm, pale inferior
palpebral conjunctiva (-/-), edema palpebra (-/-), double chin (+)
Ear/nose/mouth : within normal limit / within normal limit / within normal limit
Neck : lymph node enlargement (-)
Thorax : simetrical fusiform, retraction (-)
Heart rate : 82 beats/minute, regular, murmur (-)
Respiratory rate : 20 breaths/minute, reguler rh (-/-)
Abdomen : soft, peristaltic was normal, liver and spleen in normal limit, shifting
dullness (+)
Extremities : hand and pretibial edema (+)/(+), pulse 102 x/minute,
regular,warm, CRT< 2 seconds,
muliple hyperpigmented nodules with pus, crust and excoriations
Blood pressure 160/130 mmHg ( P 90 : 123/ 78 mmHg
P 95 : 127/ 82 mmHg
P 99 : 134/ 90 mmHg)
Differential Diagnosis :

Acute nephritic syndrome e.c

dd/-Glomerulonephritis Acute Pasca Streptococcus
- Ig A Nephropaty
+ pyoderma + obesitas
Working Diagnosis :
Glomerulonephritis Acute Pasca Streptococcus + Pyoderma + Obesitas
Therapy :
• Three way
• Nifedipine 10 mg/ sublingual
• Furosemide 2 x 40 mg
• Captopril 2 x 25 mg
• Inj Ceftriaxone 1 gr/12 jam

Planning :
• Check complete blood, ASTO, C3, Renal function, electrolyte, albumin and urinalysis
• Consultation to nutrition and metabolic disease department
• Consultation to demartology department
Time Sensorium HR RR BP Sat.O2 Temp Additional
(bpm) (tpm) (mmHg) %
02.00 CM 82 20 160/130 99 36.6 Nifedipin 10 mg sublingual
02.15 CM 88 20 150/110 99 36.6
02.30 CM 86 20 145/110 99 36.6 Check lab
02.45 CM 88 20 140/110 99 36.8
03.00 CM 80 20 140/110 99 36.7 Transfer to pediatric ward
Thank You