MORNING REPORT CASE

24th April, 2012

PATIENTS IDENTITY
Name Age Gender Ethnicity Religion Address MR Tc : IWL : 56 yo : male : Balinese : Hinduism : Selat,Karangasem : 01.55.66.67 : 16.05

ANAMNESIS

Chief complain :

pain in the epigastrium Present history : Patient complained of pain in the epigastrium since 3 days BATH. The pain suddenly appeared and presist. The pain feel like pricked by needle. And it made patient couldnt do his daily activities.

 He

also complained of nausea and vomiting since 3 days BATH. Two times vomiting, each time throwing up half of mineral water glass. Contain : food and water. History of fever 5 days BATH, but at this time he didnt got fever anymore History of pain when urinate, history of decrease in volume of urine was denied by the patient.

Past illness history

History

of pain in the epigastrium like this before was denied by the patient. The patient had a history of hypertension since 3 months ago but did not routinely control to health centers. Patients previously treated in Karangasem hospital for the same complaint. Then referred to Sanglah for further treatment. No history of using drug for long time medication.

Family history :
None

of the family member had the same complained as the patient History of HT and DM was denied

PHYSICAL EXAMINATION
General appearance : Moderately ill Level of consciousness : CM Vital Sign: BP RR HR tax Bw Bh BMI

: 140/90 mmHg : 20 x/min : 78 x/min : 36,6C : app 65 kg : app 165 cm : 24,07

Eyes

: anemis(+/+); icterus (-/-); Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (); tongue normal; lip cyanosis (-) Neck : JVP RP + 0 cmH2O; lymph node enlargement (-)

Thorax : Simetris, retraction (-) Cor Inspection : Ictus cordis unseen Palpation : Ictus cordis unpalpable Percussion : UB : ICS II LB : at MCL S ICS V RB : at PSL D Auscultation : S1 S2 single regular, murmur (-) Po Inspection : Symetric (static and dinamic) Palpation : VF N/ N Percussion : sonor/sonor Auscultation : vesikular + / + , Rh -/-, wh -/-

Abdomen : Inspection Auscultation Percussion CVA (-) Palpation in spleen not

: Distention (-); ascites (-) : Bowel sounds (+) normal : Tympani, knock pain in : Tenderness on palpation epigastrium (+); liver& palpable Ballotment (-/-)

Extremities: Warm +/+; edema -/-

Complete blood count

Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT MPV 59,10% 24,6% 8,4% 7,70% 0,20% 2,40 7,90 22,20 92,80 32,9 35,50 12,30 242,00 5,3 Result 4,70 2,80 1,20 0,40 0,00 0,00 Unit 103/L 103/L 103/L 103/L 103/L 103/L 106/L g/dL % fL pg g/dL % 103/L fL L L L L Remarks Reference range 4,5 11,00 47,00 80,00 13,0 40,0 2,00 10,00 0,00 5,00 0,0 0 2,00 4,50 5,90 13,50 17,50 41,00 55,00 80,00 100,00 26,00 34,00 31,00 36,00 11,60 14,90 150,0 440,0 6,80 10,00

Blood chemistry panel

Parameter SGOT Result 26,3 Unit U/L Remarks Reference range 11,00 33,00

SGPT
BUN Creatinine

14,4
98,0 11,52

U/L
mg/dL mg/dL mg/dL mg/dL H H H

11,00 50,00
10,00 23,00 0,50 1,20 136-145 3,5-5,1

eGFR
Na K

7,36
124 3,8

Urinalysis
Parameter
pH Leucocyte Nitrite Protein Glucose Ketone Urobilinogen Bilirubin Erytrocyte Spesific Gravity Colour SEDIMEN URINE Leucocyte Erytrocyte Silinder Others 1-2 2-4 Bactery (+) /lp /lp /lp /lp <6/lp <3/lp -----

Result
5,00 25,0 Neg 25,0 norm neg norm neg 50,00 1,01 p. Yel

Unit
Leu/uL mg/dL mg/dL mg/dL mg/dL mg/dL ery/uL -

Remarks

Reference range
58

+1 neg +1 +2 Neg Neg neg +5

Negative Negative Negative Normal Negative 1 mg/dl Negative Negative 1,005 1,020

p.yel

p. yellow - yellow

Ro. Thorax
Cor : CTR 48% Pulmo : infiltrate (-) Sinus prenicus sharp Diaphragma normal conclusion : Normal

BOF
Radioopaque appearance (+) Urinary bladder , Right ureter

ECG

Sinus rhytm Axis normal HR 76 x/min ST-T change (-

LVH (-)

ASSESMENT

CKD st V susp NO dd/PNC - Gastropati Uremicum -moderate anemia NN on CKD Susp urinary blader stone and ureter stone (Right) Hiponatremia Hypertention ST I

TX

Hospitalize Ivfd 8 tpm Omeprazole 2x40mg (IV) Domperidon 3 x 10 mg tb (PO) Asam folat 2x2 tab CaCo3 3x1 tab Captopril 2x 25 mg HD elektif

Pdx
USG

Urologi SI,TIBC,feritin Consult to urologist

Monitoring
Vital

sign Complaints

THANK YOU