mr dibon dhany
TRANSCRIPT
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MORNING REPORT
Thursday, 19ndDecember 2013
Students in Charge :
Dhany Pristianto I.
Diana Bonton
Moderator : Dr. I Putu Moda SpPD
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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.
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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.
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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,
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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
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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
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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
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ECG
(18/12/2013)
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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,
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Chest X Ray (18 Dec 2013)
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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
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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
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CUE AND CLUE PL IDx PDx PTx PMo
Female/ 50 yo
Shortnesss of breath
Pale, generalized weakness
Decrease of urine
production
Hypertension since 3 monthsago
Renal failure diagnosed 1
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
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+
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
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CUE AND CLUE PL Idx PDx PTx PMo
Female/ 50 yo
Shortnesss of breath
Decrease of urine
production
Hypertension since 3months ago
Renal failure diagnosed 1
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
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
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CUE AND CLUE PL IDx PDx PTx PMo
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
BGA : Ascidosis metabolic
fully compensated alcalosis
respiratory
Lab:
Ur 298,6 mg/dlCr 31,94 mg/dl
Leucocyte 14.900
eGFR 1,13 ml/mnt/1.73m2
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
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CUE AND CLUE PL IDx PDx PTx PMo
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
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CUE AND CLUE PL IDx PDx PTx PMo
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
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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
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L/O/G/O
Thank You!