MORNING REPORT

MORNING REPORT Tuesday, desember 11 2012

Coass in charge:Firman Kurniawan ArisandyAyu Sekarani D.P

Moderator:Dr.Didi Chandra, Sp.PD KPTI

Summary of Data BaseMr.H/ 32 y.o/ W 26Chief Complain : Epigastric pain The patient suffered from epigastric pain, nausea, and vomitting since yesterday. He vomited 5 times in a day, just water. He suffered decreased of appetite since 3 weeks ago, just ate 2 times a day 4-5 sponfull of rice. His complained followed general weakness since a week ago He suffered from both legs swelling since 2 weeks ago. He Sleep with 2 pillows because when sleep with 1 pillow he felt SOB. Lately, patient ussually felt SOB when walking. Patient often woke up in the night because shortness of breath since a month ago.

He had history drank traditional potion once a week for 2 years. He drank it for his all body pain. The traditional potion was jamu pegel linu. He has been worked as a foreman at bali since 2 months ago and he went back to the java since he felt his body swelling especially his leg History of DM (-). Since a year ago, patient known that he had hypertension but Px not routinely controled and not tooked medicine. BAB and BAK in the normal limit

Physical examinationBP = 170/100mmHgPR = 85 bpm strong regulerRR = 24 tpmTax : 37,6 CGeneral appearance looked severely illGCS 456; Compos mentis, Looked normoweightHeadAnemic +/+Icteric -/-NeckJVP R + 3 cm; 30Thorax: Cor:Ictus invisible and palpable at 2 cm lateral MCL ICS VI SinistraRHM SL DextraLHM ictusS1, S2 single with no murmur, Lung: Symmetric, SF D = S, v v No additional breath sound v v v vAbdomenFlat, soefl, liver span 8 cm, troube space tympani, shiffting dullness (-)ExtremitiesWarm, Leg pitting edema +Laboratory findingLabValueLabValueLeukocyte98903.500-10.000/LNatrium132136-145 mmol / LHaemoglobine5,811,0-16,5 g/dlKalium6,963,5-5,0 mmol / LMCV83,30Chloride 11298-106 mmol/LMCH28,40PCV17 35-50%Trombocyte201.000150.000-390.000/LRBS116SGOT1311-41U/LUreum435,6010-50 mg/dLSGPT710-41U/LCreatinine31,380,7-1,5 mg/dLLaboratory FindingBGAValue(Suplemental O2 4 Lpm)PH7, 167,35-7,45PCO212,7 mmHg35-45PO2105,6mmHg

80-100HCO34,6 mmol/ l21-28O2 saturation96,6 %> 95%Base Excess-23,3-3 until +3ConclussionAcidosis Metabolik partially compensated

ECGSinus rhythm, Heart rate 100bpm PR interval :0,12''QRS complex: 0,08ST interval:0.30Frontal Axis: NormalHorizontal Axis: NormalConclusion : sinus rhythm, heart rate 100 bpm

CXRAP position, asymetric, enough KV, enough inspirationTrachea in the middleSoft tissue and bone normalHemidiaphragma D and S dome sharp Phrenico costalis angke D/S sharpCor site and shape are normal, CTR: 60%Conclusion: Cardiomegaly CTR>60%CUE AND CLUEPLIDxPDxPTxPMoMr.H/32yo/W26He has been consumining traditional potion once a week for 2 years.Hipertensional known when admission Leg swelling since 2 weeks agoNause, vomitingPale skin and general weakness

PEConj. Anemis +/+Leg edema +/+

LabAnemia NN: 5,8Ur/Cr: 435,6/31,38eGFR: 1,73K: 6,96BGA: asidosis metabolik1. CKD stage VNewly diagnose1.1. NSAID Nephropathy1.2. HT nefrosklerosis USG AbdomenO2 8-10 Lpm (NC)Semiflower position Iv plugFluid balance negatif 500-1000 cc/hr

Low protein diet 1900 kcal/day (0,6-0,8g/kg/day), protein 0,5-0,8 gr/day, RG