MORNING REPORT

Wednesday, 2017

Spv: dr.
 SUMMARY OF DATA BASE
Mrs. / yo/Ward 2
HISTORY TAKING :
CHIEF COMPLAINT :
HISTORY OF PRESENT ILLNESS :
Patient came to the hospital because of pain in all abdomen region. Patient also felt
nausea and vomit since a month ago. Patient vomitted every time she ate. Patient also
loss of appetite and lost 5 kg of her weight in just a month.
Patient also complain that she felt pain in epigastrium. There are no history of nausea
and vomit before. One and a half month ago patient told that she felt pain at lumps in
her back. Today, patient still felt pain in that wound.
SUMMARY OF DATA BASE
 Physical Examination
Looked weight
General Appearance:

GCS: 456 120/80 mmHg HR : 80x bpm RR : 22 tpm Tax : 36.6 C

Head Anemic conjunctiva (+) icteric sclerae (-).

Neck JVP: R + cm in 30 position Lymphonode enlargement
Wall Chest expansion

Chest Ictus invisible, palpable ICS Trill: - Heaves:

Heart
S1 and S2 single, no murmur

Stem Fremitus D=S SS v v Rh - - Wh - -

SS v v - - - -
Lung SS v v - - - -
Percussion :
Tenderness (+) in all region of lung
Flat, bowel sound (+) normal, epigastrial tenderness (-), liver span 6 cm, Traubes space
Abdomen
(+).

Extremities Warm, edema (-)

 LABORATORY FINDING (May, 23rd 2016) Ny. Sri Sundari
Lab Value (Normal) Lab Value (Normal)
Hemoglobin 7.5 11,4 - 15,1 g/dl Natrium 130 136-145 mmol/L
leukocyte 16,360 4.700 11.300 /L Kalium 4,38 3,5-5,0 mmol/L
PCV 22,8% 38 - 42% Chlorida 104 98-106 mmol/L
Trombocyte 446000 142.000 424.000 /L

MCV 88,70 80-93 fl

MCH 29,20 27-31 pg

Eo/Bas/Neu/ 1,3/0,6/74.1/12.8/ 0-4/0-1/51-67/25-33/2-5

limf/Mon 11.2

GDS 195 < 200 mg/dl

Ureum 76 16,6 - 42,5mg/dl

Creatinine 7,43 < 1,2 mg/dl

E-GFR 10 > 90/ Mil/min

BGA Result (may 23 rd 2017)

Temp 37,0 C Nasal canule 4 lpm

pH 7,43 7.35-7.45
pCO2 29.8 35 45 mmHg
pO2 118.3 80 100 mmHg
HCO3 20.1 21 28 m mol/L
O2 saturation 96,4 > 95 %
True 02 97
BE -4.4 (-3) - (+3) m mol/L
Hb 9.1
Conclusion : Acidosis metabolic compensated with alcalosis respiratory
Blood smear
ECG (May, 23 2017) Ny Sri Sundari
CXR (23/05/2017)
CXR: 23-05-2017

Interpretation :

AP position, symetric, enough KV, less inspiration

Soft tissue normal, bone normal
Trachea in the middle
Right and left hemidiaphragm : Dome shape
Left and right phrenicocostalis angle : sharp
Lung : bronchovascular pattern was increase,
hilus D/S were normal
Heart : site normal, CTR 67%, shape bigger, cardiac waist (-), apex
embeded
Conclusion : cardiomegaly
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring
Mrs.S/40 yo/w.23 1. SOB 1.1 HF st C fc III Echocardiography O2 4 lpm (NC) Subjective
AX : Bed rest Vital Sign
Shortness of Breath 1 w 1.2 Inadequate HD semifowler Urine production
Dyspnea the effort
position Fluid Balance
PND
Last HD was monday Renal diet 1700
Hypertension 1 years kcal/day, low salt PEdu:
PE : < 2 gram/day, Disease
BP : 150/100 mmHg protein 0,6-08 Underlying disease
RR : 24 tpm gr/kgBW/ day Treatment Prognosis
PR : 86 tpm
Anemic conjungtiva : Iv plug
(+/+)
Inj Furosemide 3x
Ronkhi + mediobasal /+
basal , dullness at basal 40 mg (iv)
lung dextra/ sinistra
Cor : ictus ICS V AAL S
LF :
Hb :7.50 g/dL
Ur : 76 mg/dL
Cr : 7,43 mg/dL
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring

Mrs.S/40 yo/w.23 2. HF st C fc III 2.1HHD Echocardiograph Bedrest Subjective

AX :
2.2 Diabetic y O2 4 lpm via Vital Sign
Shortness of Breath
1 week cardiomiopathy nasal canule CBC
Dyspnea the effort low sodium
PND, oedema,she <2gram/day, PEdu:
suffered DM 2 years
Disease
ago, and
hypertension 1 years Valsartan 0-0- Underlying disease
ago 80mg Treatment
PE : Prognosis
BP : 150/100 mmHg
RR : 24 tpm
PR : 86 tpm
Anemic conjungtiva :
(+/+)
Ronkhi + + basal ,
dullness at basal
lung dextra/ sinistra
Cor : ictus ICS V AAL
S
LAB
RBS : 195
CXR
Cardiomegaly
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring
Mrs.S/40 yo/w.23 3. CKD stage 5 3.1HT Bedrest Subjective
AX :
Shortness of Breath 1 w nephrosclerosis O2 4 lpm via Vital Sign
Dyspnea the effort 3.2 Diabetic nasal canule Ureum creatinine
Last HD was Monday
Diagnosed CKD since 2 kidney disease Renal diet 1700 urine production
years ago kcal/day, low
she suffered DM 2 years
ago, and hypertension 1
sodium PEdu:
years ago <2gram/day, Disease
PE : protein 0,6-0,8 Underlying disease
BP : 150/100 mmHg
RR : 24 tpm gr/kgBW/ day Treatment
PR : 86 tpm Prognosis
Anemic conjungtiva :
(+/+) Negative fluid
Ronkhi + /+ basal , balance 500
dullness at basal lung
dextra/ sinistra
cc/day
Oedema all extrimities
LF : HD on
Hb :7.50 g/dL
Ur : 76 mg/dL schedule
Cr : 7,43 mg/dL
eGFR : 10
RBS : 195
BGA :
Acidosis metabolic
compensated with alcalosis
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring

Mrs.S/40 yo/w.23 4. HT stage 2 on 4.1 Secondary valsartan 0-0-80 Subjective

AX : treatment Hypertension mg Vital Sign, defisit
She has HT since 1 4.1.1 neurology
years ago Renoparenchymal
PE : hypertencion PEdu:
TD : 150/100 4.1.2 Renovascular Disease
mmHg hypertension Underlying disease
4..2 Primary Treatment Prognosis

Mrs.S/40 yo/w.23 5. Anemia 5.1 Anemia renal Blood smear Transfusi PRC Subjective
AX :
Weakness, Fatigue
Normochromic 250cc/ day Vital Sign
Looked pale normocyter PEdu:
conjunctiva anemia (+) Disease
Underlying disease
PE :
Pale conjuctiva Treatment Prognosis

LF :
Hb : 7,5 g/dL
MCV : 88.70 fl
MCH : 29,20 pg
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring

Mrs.S/40 yo/w.23 6. DM type II on Fasting blood Continue the Subjective

AX : glucose insulin, add dose Vital sign
insulin
Diagnosed DM since
2 years, routinly 2 hour post fasting if needed Fasting blood glucose
took insulin blood glucose 2 hour post fasting
blood glucose
PE :
-
LF :
RBG : 195 gr/dl
 Condition this morning :
GCS 456
BP :160 /100mmHg
PR : 90 bpm
Tax : 36,00C
RR : 22x/minute
Thank You