MR Dibon Dhany

8/13/2019 MR Dibon Dhany

1/19

MORNING REPORT

Thursday, 19ndDecember 2013

Students in Charge :

Dhany Pristianto I.

Diana Bonton

Moderator : Dr. I Putu Moda SpPD


2/19

Summary of Data Base

Female/50 yo/W26

Chief Complain : Shortness of Breath

Patient came to the hospital with complaint shortness of breath.

Shortness of breath since days before admission. Patient feelshortness of breath when doing activity. It was better when the patient

rest. She sleep with 2 pillow. She also feel shortness of breath with

cough. The cough sometimes with wihite sputum and liquid. It was feel

when the patient would have sleep. If she tried to walk far away (about

10 m) the patient feel tiredness n palpitation. Paroxysmal NocturnalDyspneu (-), Orthopneu (+)

Patient also suffered nausea and vomiting since 3 months ago.

Nausea and vomit appear when the patient touch the water. The colors

of vomit is white. Bloody vomit (-) Fever (-). The patient have history of

hypertension since 3 months ago. The highest blood pressure until200/100 mmhg.


3/19

History of Past Illness : Patient didnt have

experienced hospitalization

History of Past Medical Treatment : Patient was

consume antihypertension drugs, but she forget

the name of the drugs. But she is not routinly

consume the drug. Family History : -

Social History : She is a housewife, with 2

daughters.


4/19

PHYSICAL EXAMINATION

BP : 150 /100 (ward) PR : 115strong (ward) RR : 32tpm, Tax : 36,7 0C

General appearance : looked moderately ill GCS 456 ; Looked normoweight

Head Pale conjunctiva + ,icterus - , Lymp enlargement (-),

Neck R+ 5 cm H2O (30)

Thorax : Cor Ictus invisible and palpable at ICS VI MCL 3 cm lateral sinistra

LHM ~ ictus RHM ~ Parasternal line D

S1, S2 single m(-) g(-)

Pulmo Symmetric, bronchovesicular at all area, rhonci - - , wheezing - -

+ + - -

+ + - -

Abdomen soefl, bowel sound normal, liver span 8 cm, Shifting dullness (-), traube

space (tympany)

Extremities Warm acral, no edema,


5/19

LABORATORY FINDINGS

Lab Value Lab Value

Leucocyte 14.900 4000-11.000/L Na 129 136-145mmol/l

Diff Tell 0/0,1/90,

5/6,2/2,8

0-4/0-1/51-67/25-

33/2-5 %

K 6,38 3,5-5,0 mmol/l

Haemoglobin 8,3 11-16,5 g/dL Cl 101 98-106 mmol/l

MCV 86,3 80-93 fl Osm 331,54

MCH 29,4 27-31pg

MCHC 34,1 40-47 %

Thrombocyte 236.000 150-450x103/L Ureum 298,60 16,6-48,5 mg/dL

SGOT/AST 71 11-41U/L Creatinin 31,94 < 1,2 mg/dL

SGPT/ALT 59 11-41U/L

Alb 3,57 3.5-5.5 g/dL


6/19

URINALISIS

Lab Value Lab Value

Cloudy Clody Clear 10 x

Color Yellow Yellow Epitel 4 - 6 1lpf

pH 6 4,5 - 8,0 Cilinder - Lpf

BJ1,020

1,0101,015 Hialin - 2Glucose 1 Negative Granular - Negative

Protein +3 Negative 40 x

Keton - Negative Erythrocyte 10 12 3 hpf

Bilirubin +2 Negative Dysmorfic - Hpf

Urobilinogen +3 Negative Eumorfic + Hpf

Nitrit - Negative Leucocyte 22,5 5 hpf

Leucocyte 3-4 Negative Cristal - hpf

Blood +3 Negative Bacteria + 23 x 103/mL


7/19

BLOOD GAS ANALYSIS

Lab Value

PH 7,31 7,357,45

PCO2 26,5 3545

PO2 117,7 80100

Bikorbonat

(HCO3)13,6 2128

Kelebihan Basa

(BE)-12,8 (-3)(+3)

Saturasi O2 95 % 95


8/19

ECG

(18/12/2013)


9/19

ECG Sinus tachicardia heart rate 115 bpm

Frontal Axis : N

Horizontal Axis : Normal Axis

PR interval : 0,12

QRS complex : 0,06 QT interval : 0,28

Conclusion : Sinus tachycardia heart rate 115bpm,


10/19

Chest X Ray (18 Dec 2013)


11/19

AP position, symetric, KV strong, enough inspiration

Trachea in the middle

Soft tissue and bone normal

Right and left phrenico-costalis angle are blunt

Right and left hemidiaphragm are not visible,

Pleural efusion in the basal of the right lung

Infiltrat in all area of the lung dex/sin

Airbroncogram (+) Cor site N, size : CTR 58 % , heart waist (-)

Conclusion : Normal chest x ray Cardiomegaly, uremic

lung, n pneumoniae

CXR


12/19

CUE AND CLUE PL IDx PDx PTx PMo

Female/ 50 yo

Shortnesss of breath

Hypertension since 3

months ago

Renal failure diagnosed 1

day before admissionPE:

BP:150/100 mmHg

RR: 32 tpm

PR :115 tpm

JVP R+5 cm H2O

Pale conj. (+)

Rh in middle n basal lung D/S

CXR: cardiomegaly,uremic

lungBGA : Ascidosis metabolic

fully compensated alcalosis

respiratory

Lab:

Ur 298,6 mg/dl

Cr 31,94 mg/dl

Leucocyte 14.900

eGFR 1,13 ml/mnt/1.73m2

UL : Protein 3+

1.Shortnes

s of breath

1.21 Non

cardiogenic dt

uremic lung dt CKD

stage 5

1.2.Cardiogenic dt

HF stage C fc III

-O2 8-10 lpm NRBM

-Bed rest + Semifowler position

-Fluid balance negative 500cc/day

-Inj.furosemide 40-40-40 mg (iv)

Subjective

BP

HR

RR

Urine

production

Education

family

abaout the

Disease,

diagnostic

tools, and

treatment


13/19


Female/ 50 yo


Pale, generalized weakness

Decrease of urine

production

Hypertension since 3 monthsago


day before admission

PE :

BP :150/100 mmHg

RR : 32 tpm

PR :115 tpm

JVP R+5 cm H2O

Pale conj. (+)Rh in middle n basal lung D/S

CXR: cardiomegaly,uremic

lung

BGA : Ascidosis metabolic


respiratory

Lab:

Ur 298,6 mg/dl

Cr 31,94 mg/dl

Leucocyte 14.900


UL : Protein 3+

2. Acute

on CKD

stage 5

2.1 HT

nephrosclerosis

2.2

Glomerulonephritis

chronic

2.3 Pyelonephritischronic

USG

Abdomen

Renal Diet 1900 kcal/day

Low salt


14/19

CUE AND CLUE PL Idx PDx PTx PMo

Female/ 50 yo


Decrease of urine

production

Hypertension since 3months ago


day before admission

PE:

BP :150/100 mmHg

RR : 32 tpm

PR :115 tpm

JVP R+5 cm H2O

Pale conj. (+)

Rh in middle n basal

lung D/S

CXR:

cardiomegaly,uremic lung


fully compensatedalcalosis respiratory

Lab:

Ur 298,6 mg/dl

Cr 31,94 mg/dl

Leucocyte 14.900

eGFR 1,13

ml/mnt/1.73m2

UL : Protein 3+

3. HT

Stage II

2.1.Secondary

HT dt CKD stage

5

2.2 Primary HT

PO : Captopril : 25 mg x 2 Subjecti

ve

BP

HR


15/19


Female/ 50 yo

Shortness of breath

Dyspneu d effort

Orthopneu

Hypertension since 3

months agoRenal failure diagnosed 1 day

before admission

PE:BP :150/100 mmHgRR : 32 tpm

PR :115 tpm

JVP R+5 cm H2O

Pale conj. (+)

Ictus invisible and palpable at

3 cm lateral MCL S, ICS VILHM ~ ictus

RHM ~ SL D

S1, S2 single with no murmur

no gallop

Rh in middle n basal lung D/S

CXR : Cardiomegaly,Uremic

lung



respiratory

Lab:

Ur 298,6 mg/dlCr 31,94 mg/dl

Leucocyte 14.900


UL : Protein 3+

4. Heart

failure stage

C fc III

4.1 Hypertension heart

disease

4.1 Uremic

cardiomyopathy

Echocardi

ography

O2 8-10 lpm NRBM

Bed rest and semifowler position

Inj.furodemide 40-40-40 mg (iv)

Subjectiv

e

BP

HR

RR

Urine

productio

n

CUE AND CLUE PL ID PD PT PM


16/19


Female/ 50 yo

- Shortness of breath

- Cough

Rh in middle and basal

basal lung D/S

Port score 153 RC 5

CXR: cardiomegaly,uremic lung, pneumonia

Lab:

Leucocyte 14.900

5. Acute lung

infection

5.1.Pneumonia

CAP

5.2.Bronchitis

acute

Sputum

culture and

sensitivity,

gram

-inj. Ceftriaxon 2x1 gram

- levofloxacin 1x 250 mg

- Po: ambroxol 3x30 mg

Subyektif

Female/ 50 yo

Pale

Generalized weaknessPE : pale conjungtiva

Lab:

Hb 8,3 g/dl

MCV 86,30 /l

MCH 29,40 pg

6. Normochrom

Normocyter

Anemia

6.1 def.

Eritropoeitin due

to CKD

Blood

smear,

reticulocytecount,

Treat underlyng disease Subj

Hb

Female/ 50 yo

Pale

Generalized weakness

PE : pale conjungtivaLab:

Na : 128 mmol/L

Osm : 331,54

7. Hiponatremia

Hiperosmolar

IVFD NS 3 % 500cc in 18 hours 10

dpm

Subj, Na

CUE AND CLUE PL ID PD PT PM


17/19


Female/ 50 yo

Pale

Generalized weakness

PE : pale conjungtiva

Lab:

K : 6,13 mmol/ L

8. Hiperkalemia Koreksi Hiperkalemia

Ca Gluconase 100 mg

Dextrose 40% 2 Flash

Actrapid 10 IU

Subyektif,

Cek

Kalium


18/19

Condition this morning

Subjective : No complaint (+)

GCS 456

BP 140/90 mmHg PR 88 bpm, regular, strong

RR 28 tpm,

Rh in medial n basal lung D/S Urine production 50 cc in 6 hours


19/19

L/O/G/O

Thank You!

MR Dibon Dhany

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