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    Morning Report Case: June 19, 2014

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    Sri Dashinie
    - The patient is a 60-year-old Balinese Hindu man who presented with nausea, vomiting, cough, leg swelling, difficulty urinating, and shortness of breath for the past week. - Physical examination found elevated blood pressure, abnormal lab results, and lung edema on chest x-ray. - The assessments were end-stage renal disease, suspected diabetic ketoacidosis, melena possibly from uremic gastropathy, lung edema, metabolic acidosis, anemia, and hyperuricemia. Treatment included hemodialysis, medications, monitoring, and further tests.

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    Morning Report Case: June 19, 2014

    Uploaded by

    Sri Dashinie
    22 views23 pages
    - The patient is a 60-year-old Balinese Hindu man who presented with nausea, vomiting, cough, leg swelling, difficulty urinating, and shortness of breath for the past week. - Physical examination found elevated blood pressure, abnormal lab results, and lung edema on chest x-ray. - The assessments were end-stage renal disease, suspected diabetic ketoacidosis, melena possibly from uremic gastropathy, lung edema, metabolic acidosis, anemia, and hyperuricemia. Treatment included hemodialysis, medications, monitoring, and further tests.

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    - The patient is a 60-year-old Balinese Hindu man who presented with nausea, vomiting, cough, leg swelling, difficulty urinating, and shortness of breath for the past week. - Physical examination found elevated blood pressure, abnormal lab results, and lung edema on chest x-ray. - The assessments were end-stage renal disease, suspected diabetic ketoacidosis, melena possibly from uremic gastropathy, lung edema, metabolic acidosis, anemia, and hyperuricemia. Treatment included hemodialysis, medications, monitoring, and further tests.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    22 views23 pages

    Morning Report Case: June 19, 2014

    Uploaded by

    Sri Dashinie
    - The patient is a 60-year-old Balinese Hindu man who presented with nausea, vomiting, cough, leg swelling, difficulty urinating, and shortness of breath for the past week. - Physical examination found elevated blood pressure, abnormal lab results, and lung edema on chest x-ray. - The assessments were end-stage renal disease, suspected diabetic ketoacidosis, melena possibly from uremic gastropathy, lung edema, metabolic acidosis, anemia, and hyperuricemia. Treatment included hemodialysis, medications, monitoring, and further tests.

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    © All Rights Reserved
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    Download as ppt, pdf, or txt
    of 23

    MORNING REPORT

    CASE
    June 19
    th
    ,
    2014

    PATIENTS IDENTITY
    Name : KS
    Age : 60 yo
    Gender : Male
    Ethnicity : Balinese
    Religion : Hindu
    Address : JL Pulau Singkep
    MR : 14036830


    ANAMNESIS
    Chief complain :
    nausea
    Present history :
    Patient came with chief complain of nausea
    since 7 days BATH. It worsened day by day
    and there were no factor that could relieve
    this symptom
    Patient also complained about vomitting
    which were started since 7 days BATH. He
    vomitted 3 times per day and volume of each
    vomit was about glass of aqua. The
    contain of the vomit was food which are
    consumed by the patient beforehand.





    He coughed since 7 days BATH.
    Productive cough with yellowish phlegm.
    There was no blood in the phlegm.
    He also complained about swollen in his
    leg.
    The patient difficult to urinate since 4 days
    BATH and the volume of urin decreased
    by day. 1 day BATH, patient couldnt
    urinate.
    breathlessness since 2 days BATH, and
    worsening since yesterday. Symptom felt
    better if the patient sit up and lean
    forward. Wheezing was denied.
    stool turned black since 3 days BATH. The
    consistency was soft, frequency was 2-3
    times a day and it accompanied by pain in
    lower abdomen. It was about half of glass on
    each defecation. On the admissions day,
    there was no blacky stool.
    4 days BATH, the patient also had nausea
    and vomitted a few times, approximately
    glass each, containing food & saliva. But
    stopped since 1 day BATH. Blood (-)
    cough (-), fever (-)
    Medication history :
    Two days ago, the patient came to Bakti
    Rahayu with a chief complaint of blacky
    stool. The patient received :
    Mixtat 20 IU, Acetosal 1x , biosanbe
    1x1, lasix 1 amp, transf. PRC 1 kolf
    The patient was then referred to Sanglah
    hospital because of swollen body and
    decrease of conciousness
    Past illness history
    Patient had the history of diabetes melitus
    since 4 years ago and was on insulin injection
    and oral medication but forget the name of the
    drug.
    Patient also had a history of hypertension
    since 2 years ago but the family unclear of the
    details of the medications.
    6 month ago, patiet had a history of urinating
    stones.

    Family history :
    None of the family member had the same
    complained as the patient
    History of renal abnormalities, HT, and DM
    was denied

    Social History :
    Alcohol consumption and smoking was
    denied. Jamu consumption was also denied.




    PHYSICAL EXAMINATION
    General appearance : Moderately ill
    Level of consciousness : compos mentis
    GCS : E
    4
    V
    5
    M
    6
    Vital Sign:
    BP : 160/100 mmHg
    RR : 18 x/min
    PR : 88 x/min
    t
    ax
    : 36,7C
    Body weight : 84 Kg
    Height : 170 cm
    BMI : 29,06 kg/m
    2
    Eyes : conj. Pale (+/+); icterus (-/-);
    Rp +/+ isocoric, oedema palp. (-/-)

    ENT : Tonsils T1/T1; pharyngeal hyperemia (-
    ); tongue normal; lip cyanosis (-)

    Neck : JVP RP + 2 cmH
    2
    O;
    lymph node enlargement (-)




    Thorax : Simetris, retraction (-)
    Cor
    Inspection : Ictus cordis unseen
    Palpation : Ictus cordis not palpable
    Percussion :
    UB : ICS II
    LB : at MCL S ICS V
    RB : at PSL D
    Auscultation : S1 S2 single regular, murmur (-)

    Po
    Inspection : Symetric
    Palpation : VF N/ N
    Percussion : /dull
    Auscultation : vesikular + / + , Rh -/-, wh -/-

    Abdomen :
    Inspection : Distention (-); ascites (-)
    Auscultation : Bowel sounds (+) normal
    Percussion : Tympani
    Palpation : Tenderness on palpation
    (-); liver & spleen not palpable
    Ballotment (-/-)



    Extremities: Warm +/+; edema -/-
    +/+ -/-


    Complete blood count

    Parameter Result Unit Remarks Reference range
    WBC 7,40 10
    3
    /L 4,5 11,00
    -Ne 90,50% 6,70 10
    3
    /L H 47,00 80,00
    -Ly 7,1% 0,50 10
    3
    /L L 13,0 40,0
    -Mo 2,10% 0,20 10
    3
    /L 2,00 10,00
    -Eo 0,10% 0,00 10
    3
    /L 0,00 5,00
    -Ba 0,20% 0,00 10
    3
    /L 0,0 0 2,00
    RBC 2,93 10
    6
    /L L 4,50 5,90
    HGB 9,10 g/dL L 13,50 17,50
    HCT 25,40 % L 41,00 55,00
    MCV 86,8 fL 80,00 100,00
    MCH 31,20 pg 26,00 34,00
    MCHC 36,00 g/dL 31,00 36,00
    RDW 12,70 % 11,60 14,90
    PLT 385,00 10
    3
    /L 150,0 440,0
    MPV 6,70 fL 6,80 10,00
    Blood chemistry panel
    Parameter Result Unit Remarks Reference range
    SGOT 27,75 U/L 11,00 33,00
    SGPT 20,06 U/L 11,00 50,00
    BUN 100,90 mg/dL H 10,00 23,00
    Creatinine 13,73 mg/dL H 0,50 1,20
    eGFR 6,47 ml/min
    Uric Acid 10,79 mg/dL H 2,00 7,00
    Random blood
    glucose
    321 mg/dL H 70,00 140,00
    Blood Gas Analysis
    Parameter Result Unit Remarks Reference range
    pH 7,34 - L 7,35 7,45
    pCO
    2
    39,00 mmHg 35,00 45,00
    pO
    2
    73,00 mmHg L 80,00 100,00
    Hct 25,00 % L 37,00 48,00
    HCO
    3
    -
    21,00 mmol/L L 22,00 26,00
    TCO
    2
    22,20 mmol/L 24,00 30,00
    BE(B) 4,40 mmol/L -2 2
    SO
    2
    c 93,00 % --
    THbc 7,80 g/dL 13,00 18,00
    Natrium 100,00 mmol/L L 136,00 145,00
    Kalium 3,40 mmol/L L 3,5 5,1
    Urinalysis
    Parameter Result Unit Remarks Reference range
    pH 5,00 - 5 8
    Leucocyte Neg Leu/uL +2 Negative
    Nitrite Neg - neg Negative
    Protein 500,00 mg/dL +4 Negative
    Glucose 100,00 mg/dL +2 Normal
    Ketone neg mg/dL Neg Negative
    Urobilinogen norm mg/dL Neg 1 mg/dl
    Bilirubin neg mg/dL neg Negative
    Erytrocyte 25,00 ery/uL +5 Negative
    Spesific Gravity 1,015 - 1,005 1,020
    Colour p. Yel - p.yel p. yellow - yellow
    SEDIMEN URINE
    Leucocyte 0-1 /lp <6/lp
    Erytrocyte 1-2 /lp <3/lp
    Silinder Granular (+) /lp ---
    Others Bactery (+) /lp ---
    Ro. Thorax
    Cor :
    CTR 59%
    Pulmo :
    Perivascular haziness in
    both lung
    Conclusion :
    Lung edema
    Cardiomegaly

    BOF
    Radioopaque
    appearance (-)

    ECG
    Sinus rhytm
    Axis normal
    HR 76 x/min
    ST-T change (-
    )
    LVH (-)
    Conc. : Normal
    ASSESMENT
    CKD stage V ec suspect DKD dd PNC
    - DOC ec Suspect ensefalopaty uremium dd:/ hiponatremia
    - Melena ec suspect gastropaty uremium
    - Lung edema
    - Acidosis Metabolic
    - Mild anemia Normocromic Normositter on CKD
    - Hyperuricemia
    Hiponatremia hipoosmolar Cronic asymptomatic hypervolemic
    DM type II
    Suspect HHD / fc II
    - Hypertension stage 2


    PLANNING
    Therapy
    MRS
    O2 4 liter per minute
    IVFD NaCl 0,9% 8 dpm
    Fasting
    NGT with gastric cooling blood (+)
    HD emergency free heparin
    Pantoprazole 2x40 mg
    Antasid 3 xCI
    Sulcrafat 3 x CII
    Drip Novorapid 4 IU/jam until BS 200
    - drip novorapid 1 IU/ jam with D5%
    Ramipril 1 x 5 mg
    CaC03, Folic Acid and Allopurinol (postponed)
    Pdx
    Blood smear
    SI, TIBC, Ferritin
    USG Abdomen
    HbA1c, Lipid Profil
    Consult opthalmology

    Monitoring
    Vital sign
    Bleeding, counciousness
    Complaints
    Fluid Balance
    Blood sugar @ 1 hour
    Blood Gas analysis post HD
    Electrolyte


    THANK YOU

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