Scribd Logo
Upload

Welcome to Scribd!

  • 30 views

    Morning Report: Department of Internal Medicine

    Uploaded by

    andrirombe
    This morning report from the Department of Internal Medicine at the Christian University of Indonesia discusses a 56-year-old male patient, Mr. K, who presented with edema of the eyelids, hands, and feet for the past three months. The patient has a history of diabetes mellitus and was recently diagnosed with kidney disease. On examination, he had elevated blood pressure and signs of edema. Laboratory tests showed anemia and abnormal kidney function. He was assessed as having stage 5 chronic kidney disease and anemia. The treatment plan was to admit the patient, start IV fluids and medications, monitor fluid balance and lab tests.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Morning Report: Department of Internal Medicine

    Uploaded by

    andrirombe
    30 views12 pages
    This morning report from the Department of Internal Medicine at the Christian University of Indonesia discusses a 56-year-old male patient, Mr. K, who presented with edema of the eyelids, hands, and feet for the past three months. The patient has a history of diabetes mellitus and was recently diagnosed with kidney disease. On examination, he had elevated blood pressure and signs of edema. Laboratory tests showed anemia and abnormal kidney function. He was assessed as having stage 5 chronic kidney disease and anemia. The treatment plan was to admit the patient, start IV fluids and medications, monitor fluid balance and lab tests.

    Original Description:

    CKD

    Original Title

    CKD

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This morning report from the Department of Internal Medicine at the Christian University of Indonesia discusses a 56-year-old male patient, Mr. K, who presented with edema of the eyelids, hands, and feet for the past three months. The patient has a history of diabetes mellitus and was recently diagnosed with kidney disease. On examination, he had elevated blood pressure and signs of edema. Laboratory tests showed anemia and abnormal kidney function. He was assessed as having stage 5 chronic kidney disease and anemia. The treatment plan was to admit the patient, start IV fluids and medications, monitor fluid balance and lab tests.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    30 views12 pages

    Morning Report: Department of Internal Medicine

    Uploaded by

    andrirombe
    This morning report from the Department of Internal Medicine at the Christian University of Indonesia discusses a 56-year-old male patient, Mr. K, who presented with edema of the eyelids, hands, and feet for the past three months. The patient has a history of diabetes mellitus and was recently diagnosed with kidney disease. On examination, he had elevated blood pressure and signs of edema. Laboratory tests showed anemia and abnormal kidney function. He was assessed as having stage 5 chronic kidney disease and anemia. The treatment plan was to admit the patient, start IV fluids and medications, monitor fluid balance and lab tests.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 12

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT

    October 9nd 2014


    TEAM 4
    Mr. K (56 yo)
    Findings Assessment Therapy Planning

    CC : edema palpebra, hand and foot for three month CKD grade V Pro Hospitelize
    ago. Anemia IVFD : Inj plug Check balance
    Hypertension grade II Diit : smooth with 40gr Check blood gas
    Appearance: moderate illness, GCS : E4V5M6, BP: protein analysis
    140/100 mmHg, PR : 96 x/min (adequate,regullar) RR : Mm/ Check urine/24 hours
    24 x/min, T: 36 C Bicnat 3x1
    Eye : swelling palpebra +/+ , conjuntiva not pale, Sklera CaCo3 3x1
    icteric -/- Furosemide 2x1amp
    Ear, Nose, Throat: normal (40mg)
    Neck : lymph nodes did not enlarged, venous distention - Ranitidine 2x1 amp
    THORAX
    Insp : symmetric, ictus cordis (-) Check balance
    Pal : vf symmetric, ictus cordis palpable, JVP 5+3
    Per : symmetric, sonor sound
    RHB ICS V lin. sternal dext, LHB ICS V lin.
    Midclavicula sin
    Aus : bronchial rh -/-,wh-/-
    BJ I dan II regular, murmur (-) gallop (-)

    ABDOMINAL
    Ins : stomach looks flat
    Ausc : bowel sounds + 5x
    Palp : Pressure Pain -
    Undulation(-),
    Per : timpany, shifting dulness (-),
    Per : CVA (-)
    Extremitas : edema ++/++, warm acral, CR<2,
    edema
    - -
    LAB FINDING:
    - -
    Complete Perifer Blood :
    Hb : 7,6 gr/dl Leu : 10.400 /ul ; Ht : 24,3 %
    ureum: 118, creatinine : 8,10, CCT : 9,35
    Subjective Data
    Name : Mr. K
    Address : Jakarta
    TC : thursday/9nd October 2014
    CC : edema in palpebra, foot and
    hand
    Anamnesis
    Main symptom : edema palpebra, foot and hand
    Additional symptom :-

    56 years old male patient came to hospital with complaint of


    edema in palpebra, foot and hand since three month before
    admission. The complaint came suddenly and continously. The
    symptom felt worse for two days.
    Patient has no history of hypertension, but he has diabetes
    mellitus since three years ago and he got a treatment with
    metformin. The patient told that he has go to the hospital and the
    diagnose was kidney disease.
    Past Medical History and Treatment
    the patient consume medication for kidney since 4 years ago.

    Family History
    (denied)

    Social History
    Smoke(-), Alcohol (-)
    Objective Data
    LOC : E4V5M6 ; Composmentis
    Appearance : moderate ill
    BP : 140/100 mmHg
    PR : 96 x/min (adequate,regular)
    RR : 24 x/min
    Temp : 360C
    EYE : anemic conjungtiva -/- ; ict -/-
    THORAX :
    Heart
    Ins : IC not visible
    Pal : IC palpable
    Per : RHB ICS IV lin. sternal dext, LHB ICS V lin. Midclavicula sin
    Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)
    Objective Data
    PULMO
    Insp : Static and dynamic symmetric
    Pal : VF right and left symmetric
    Perc : Sonor symmetric
    Ausc : BBS Brochial, Rhonci -/-, Wheezing -/-
    ABDOMEN
    Insp : Stomach looks flat
    Ausc : Bowel sound (+) 5x/minutes
    Pal : undulation (-)
    Perc : shifting dulnes (-)
    BACK
    Perc : CVA (+)

    EXTREMITIES
    Edema (-); warm (+); capp. Refill <2 seconds
    Clinical Laboratory
    Hb : 7,6 gr/dl
    Ht : 24,3 %
    Leukosit : 10. 400 /ul
    Trombosit: 340.000 /ul
    Ureum : 118
    Creatinin : 8,10
    Assessment

    CKD stage V
    Anemia
    Hypertension grade II
    Therapy

    Pro Hospitalized
    IVFD : Inj. plug
    Diit : Smooth, 4gr protein
    Mm/ - Furosemide 2x1amp
    (40 mg)
    - Ranitidine 2x1amp
    - CaCo3 3x1
    - Bicnat 3x1
    Planning

    Check balance
    Check blood gas analysis
    Check urine/24 hours
    Department of Internal
    Medicine
    Christian University of Indonesia

    Thank You

    You might also like