Morning Report

7th February 2011

Identity

Name : NNB Age : 84 y.o.Gender : femaleEthnicity : BalineseReligion : HinduMarital status : marriedAddress : Br. Dangin Jalan,

GuwangMR No. : 01.42.36.79Time of admission : 14.40 WITA

AnamnesisChief Complaint: breathlessness

Present history:

• The patient complained of

breathlessness since 3 days BATH,

appeared gradually and became worse

in the morning before she came to

hospital.

• The complaint was felt continously, not

affected by changing position

• Also complained weakness of the body since 1 weeks, gradually worsen

• Cough (-), fever (-), nausea (-), vomiting (-)

• Urination (+) but decrease in amount, yellowish colour, urinating pain(-), stone (-)

• Defecation (+) normal

Past history:• Patient had kidney disease and

urinary tract stone known since 3 months ago.

• Asthma (-), DM (-), HT (-), allergic (-)

Medication history:• Hemodialysis 3 months ago c.b.

kidney disease

Family history: • None of the patient’s family

members had similar complaints or diseases

Daily habits: • The patient denied any history

of using tobacco and alcohol consumption

• Patient was a housekeeper, helping her doughter in law cooking or making “canang”

Physical Examination

General appearance : moderately ill

GCS : E3V5M6BP : 110/50 mmHgRR : 28 x/minPR : 84 x/mintax : 36,7°C

BW : 60 kg

Eyes : anemia (-/-); icterus (-/-); pupillary reaction +/+ isocoric; palpebral edema +/+

ENT : no abnormalities foundNeck : no abnormalities foundThorax : simetric

Heart◦ Inspection : ictus cordis not visible◦ Palpation : ictus cordis not palpable ◦ Percussion : UB: ICS II, RB: PSL D, LB: 2 fingers left to

MCL S◦ Auscultation : S1S2 single regular murmur (-)

Lungs◦ Inspection : symmetrical, retraction (-)◦ Palpation : tactile fremitus N/N◦ Percussion : sonor/sonor◦ Auscultation : vesicular +/+; ronchi +/+; wheezing -/-

Abdomen– Inspection : distention (-); ascites

(-)– Auscultation : bowel sounds (+)

normal– Percussion : tymphani– Palpation : tenderness on palpation

(-); liver & spleen not palpable; ballotement +/-

Extremities : warm (+); edema (+)

Laboratory ExaminationsComplete Blood Count (CBC)

Parameter Result Unit Reference range

Interpretation

WBC 9,51 103/μL 4,1 – 10,9 Normal

-Ne 7,59 103/μL 2,5 – 7,5 Normal

-Ly 0,88 103/μL 1,0 – 4,0 Normal

-Mo 0,898 103/μL 0,1 – 1,2 Normal

-Eo 0,110 103/μL 0,0 – 0,5 Normal

-Ba 0,040 103/μL 0,0 – 0,1 Normal

RBC 2,13 106/μL 4,00 – 5,20 Low

HGB 6,48 g/dL 12,00 – 16,00 Low

HCT 19,3 % 36,0 – 46,0 Low

MCV 90,8 fL 80,0 – 100,0 Normal

MCH 30,4 pg 26,0 – 34,0 Normal

MCHC 33,5 g/dL 31,0 – 36,0 Normal

RDW 15,6 % 11,0 – 14,8 Normal

PLT 149 103/μL 150 – 440 Low

MPV 8,95 fL 0,0 – 100,0 Normal

Blood Chemistry Panel

Parameter Result Unit Remarks

Reference range

SGOT 18,89 U/L Normal 11,00 – 33,00

SGPT 9,66 U/L Low 11,00 – 50,00

Total Protein

6,968 g/dL Normal 6,40 – 8,30

Albumin 2,927 g/dL Low 3,40 – 4,80

BUN 106,5 mg/dL High 10,00 – 23,00

Creatinine 8,843 mg/dL High 0,50 – 1,20

• GFR : 4,4

Blood Gas Analysis

Parameter Result Unit Remarks

Reference range

pH 7,03 - Low 7,35 – 7,45

pCO2 18,0 mmHg Low 35,0 – 45,0

pO2 165,0 mmHg High 80.0 – 100,0

Hct 19,0 % Low 37,0 – 49,0

HCO3- 4,8 mmol/L Low 22,0 – 26,0

TCO2 5,4 mmol/L Low 24,0 – 30,0

BE(B) -23,8 mmol/L Low -2 – 2

SO2c 99,0 % 95,0 – 100,0

THBc 5,9 g/dL Low 13,0 – 18,0

Natrium 135,0 mmol/L 135,0 – 145,0

Kalium 4,4 mmol/L 3,4 – 4,8

X-Ray (Thorax AP)

• CTR : 54 %• COR : enlargement (-),

cardiac waist (+)• Po : infiltrate (-),

nodule (-), bronchovascular pattern rising

• Sinus pleura : Left & Right sharp

• Diaphragm : Left & Right normal

• Bones : fracture humerus sinister proximal.

• Conclusion : uremic lung

X-Ray (Plain Abdomen)

• Radioopaque at right ureter

• Interpretation: suspect ureter stone dexter

USG (Oct, 9, 2010)

USG (Oct, 9, 2010)

• Hydronephrosis Grade III Dexter ec. Post Renal

• Bilateral Nephritis• Plural Efusion

Assessment

• CKD stage V c.b. Susp. PNC d.d. NO- Uremic lung- Hydronephrosis grade III dexter- Uremic encephalopaty - Ureter stone dexter- Metabolic acidosis- Moderate anemia N-N

• Hipoalbumin (2,9) c.b. chronic inflamation

PlanningTherapy• Hospital admission• IVFD NS 8 dpm• Dietary 35 kcal + 0,8 gr protein/kgBW• O2 8 lpm• CaCO3 3 x I• Folic acid 2 x II• Tranfusion PRC 2 kolf• Hemodialysis• Natrium bicarbonat bolus 50 ml drip

75 mg in D5% 500 ml

Planning Diagnostic :• Urinalysis• USG abdomen

Monitoring :• Vital Signs• Complaints • BGA @ 6 h

THANK YOU