Documente Academic
Documente Profesional
Documente Cultură
Medicine
Christian University of Indonesia
MORNING REPORT
August, 22nd 2015
TEAM 2
Mrs E 32 YO
CC : Fever
Findings
Assesment
CKD stage
IV pre HD
e.c.
Nephropathy
HT + DM
with overload
CHF e.c.
HHD
HT grade I
DM type II
syndrome
dyspepsia
Therapy
MM/
1.Furosemide drip 5mg/hour
2.Prorenal 3x1
3.Bicnat 3x1
4.CaCO3 3x1
5.Omeprazole 2x1
6.Candesartan 1x8mg
7.Amlodipine 1x5mg
8.Glurenorus 1x30mg
Planning
Hospitalized
O2: nasal cannula 2-3 lpm
Fluid restriction 600cc/day
Measure 24hr urine
Fluid balance
Diet: 1900kkal, 40gr of protein
Check lab : SGOT/SGPT, UL,
GDS/hr
IVFD :
Inject plug
Subjective Data
Name
CM
TC
CC
Anamnesis
Main
symptom
Breathless
Additional symptom
:
:
Family History
Hypertension, Diabetes Mellitus
Social History
Smoking (-), consuming alcoholic beverages (-)
Objective Data
Thorax.
- I : Symmetrical chest wall movement, ictus cordis (-)
- Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
- Per: Sonor/Sonor
- Aus: basic breath sound vesical, rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur (-)
Abdomen.
- Ins : distended
- Aus : Bowel sound (+)
- Pal : Pressure pain (+) on epigastric, shifting dullness (+)
- Per : Timpani, percussion tenderness (+) on 9 regions
Extremity
-
Warm acral
Capillary refilling time <2 second
Edema (+)
Turgor normal
Clinical Laboratory
28/07/2015 (07.17)
H2TL
Hb : 13,1 g/dl (L)
White Blood Cell
: 7.700 /uL
Hematocrite
: 38,8%
Trombosite
: 236.000/uL
Electrolytie
Natrium
: 136 mmol/L
Kalium : 3.1 mmol/L
Chloride
: 112 mmol/L
Pre-prandial blood sugar level : 228mg/dL
Blood ureum
: 64mg/dL
Blood creatinine
: 2.67
Assessment
CKD stage IV pre HD e.c. Nephropathy HT + DM with overload
CHF e.c. HHD
HT grade I
DM type II
syndrome dyspepsia
Therapy
MM/
1.
2.
Prorenal 3x1
3.
Bicnat 3x1
4.
CaCO3 3x1
5.
Omeprazole 2x1
6.
Candesartan 1x8mg
7.
Amlodipine 1x5mg
8.
Glurenorus 1x30mg
Planning
Hospitalized
O2: nasal cannula 2-3 lpm
Fluid restriction 600cc/day
Measure 24hr urine
Fluid balance
Diet: 1900kkal, 40gr of protein
Check lab : SGOT/SGPT, UL, GDS/hr
IVFD :
Inject plug
Department of Internal
Medicine
Christian University of Indonesia
Thank You