MORNING REPORT

Duty on September 26th 2018

 I. Patient Identity
• Name : INK
• Age : 75 y.o
• Sex : Male
• Religion : Hindu
• Status : Married
• Addres : Denpasar
• Date Of Arrival : September 26th 2018 at 17:36 WITA
 Anamnesis

Chief Complaint : weakness on whole body

Present Illness
Patient come to sanglah hospital with chief complain was weakness on whole
body since 1 week ago. Patient was refered from Bali Med hospital. The
weakness is felt continously and said interfere with his activity. Patient said that
the weakness didn’t get better with resting.
 Anamnesis
Patients also complained of nausea and vomiting since 3 days ago. Patient always
feel nausea and vomiting right after he finished eating. Patient said this causes
decrease appetite. Patient vomited ±5x/day. Vomiting contain food and drinks
previously eaten by patient.
Patient also complain of decrease urination since 3 days ago. And since morning
patient hasn’t been able to urinate
Patient also complain of swollen leg, which appear around 1 week ago. Patient said
the swollen keep getting bigger
 Anamnesis

Past history
• Patient with history of prostate surgery 4 years ago
• Patient with history of bladder surgery 2 months ago
• History of other systemic diseases such as hypertention, DM, heart disease
and others is denied by the patient.
• No history of drugs or food allergy
 Anamnesis
Medication history
Patient was refered from Bali Med Hospital and was given theraphy :
• IVFD Nacl 0.9%
• Pantopump 1x40 mg IV
• Oretic 2x4mg IV
• Xepazym 2x1
• Braxidin 2x1
• Nebulizer ventoin every 8 hours
 Anamnesis
Family History
There is no family members that have same symptoms. history of other
systemic diseases such as hypertention, DM, heart disease and others in
family is denied by the patient
Social History
Patient is retired. History of smoking and alcohol consumption is denied
 Physical Examination

Present State Temperatur axilla : 36,6 0 C

 Appereance : Moderate ill Height : 160 cm

Consciousness : Compos mentis Weight : 53 kg
(GCS E4V5M6) BMI : 20,7 kg/m2
Blood Pressure : 100/80mmHg
Pulse Rate : 76x/mnt
Respiration Rate: 20x/mnt
 Physical Examination
General State
 Eyes : anemic (-/-), Pupil reflex (+/+), oedem palpebra (-/-)
 ENT : Ear : Secret (-/-), normal shape
Nose : Secret (-/-), normal shape
Throat : Tonsil T1/T1, Pharyngeal hyperemis (-)
 Neck : JVP PR 0 cmH2O, Lymph Node enlragement (-)
 Thorax : Symetric (+), Retraction (-), Deformity (-)
Cor : Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion : Righ Border : PSL Dextra
Left Border : MCL Sinistra
Upper border : ICS II Sinistra
Auscultation : S1 S2 normal, Reguler, murmur (-)
 Physical Examination
General State
 Pulmo
Inspection : Symetric
Palpation : Focal fremitus normal
Percussion : Sonor|Sonor
Auscultation : Vesikular+|+ Ronchi -|- Wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
 Abdomen
Inspection : Distention (-)
Auscultation : Bowel Sound (+) normal
Palpation : Abdominal pain (-) epigastrium, Hepar/Lien Unpalpable
Percussion : Tympanhy (+), CVA
 Ekstremity : warm +|+ Edema -|-
+|+ +|+
 Laboratory Examination : DL
26/09/2018
Parameter Results Unit Reference Remark Parameter
Range s
Darah Lengkap (DL) WBC 10.72 10µ/&microL 4.1 - 11.0
NE% 63.38 % 47 - 80
LY% 27.88 % 13 - 40
MO% 6.82 % 2.0 - 11.0
EO% 1.51 % 0.0 - 5.0
BA% 0.41 % 0.0 - 2.0
NE# 6.79 10µ/&microL 2.50 - 7.50
LY# 2.99 10µ/&microL 1.00 - 4.00
MO# 0.73 10µ/&microL 0.10 - 1.20
EO# 0.16 10µ/&microL 0.00 - 0.50
BA# 0.04 10µ/&microL 0.0 - 0.1
RBC 5.03 106/&microL 4.5 - 5.9
HGB 13.28 g/dL 13.5 - 17.5 Rendah
HCT 40.53 % 41.0 - 53.0 Rendah
MCV 80.53 fL 80.0 - 100.0
MCH 26.38 pg 26.0 - 34.0
MCHC 32.76 g/dL 31 - 36
RDW 11.92 % 11.6 - 14.8
PLT 271.70 10µ/&microL 150 - 440
MPV 5.62 fL 6.80 - 10.0 Rendah
PPT/INR PPT 13.2 detik 10.8 - 14.4
INR 1.04 0.9 - 1.1
APTT APTT 26.5 detik 24 - 36
 Laboratory Examination : DL
26/09/2018

Parameter Results Unit Reference Remarks Parameter

Range
HBsAg (Elisa)
HBsAg Non-reactive COI Non Reaktif : < 0.90 Borderline : ?
0.90 - < 1.0 Reaktif : ? 1.0

Anti HCV (Elisa) Anti HCV Non Reaktif COI Non Reaktif : < 0.90 Borderline : ?
0.90 - < 1.0 Reaktif : ? 1.0
SGOT AST/SGOT 12.8 U/L 11.00 - 33.00
SGPT ALT/SGPT 6.00 U/L 11.00 - 50.00 Rendah
Alkali Phosphatase(ALP) Fosfatase alkali (ALP) 47 U/L 53 - 128
Total Protein (TP) Protein Total 6.5 g/dL 6.40 - 8.30
Albumin Albumin 4.1 g/dL 3.40 - 4.80
Globulin Globulin 2.4 3.2 - 3.7 Rendah
Gamma GT Gamma GT 14 U/L 11.00 - 49.00
BS Acak / Glukosa Acak / Glukosa Darah 104 mg/dL 70 - 140
Glukosa Sewaktu (Sewaktu)
BUN / Ureum BUN 11.30 mg/dL 8.00 - 23.00
Creatinin Kreatinin 0.95 mg/dL 0.70 - 1.20
Kalium (K) Kalium (K) - Serum 3.80 mmol/L 3.50 - 5.10
Natrium (Na)
Natrium (Na) - Serum 139 mmol/L 136 - 145
Bilirubin Lengkap Bilirubin Total 0.29 mg/dL 0.30 - 1.30
Bilirubin Direk 0.10 mg/dL 0.00 - 0.30
Bilirubin Indirek 0.19 mg/dL
Thorax AP (26/9/18)

• Cor: looks enlarged, CTR 60%

• Pulmo: infiltratest on right-left paracardial.
Cephalization (+)
• Sinus pleural blunt on left and right
• Right diaphragma normal, left covered with
• Bones: osteophyte appears in the thoracal
vertebrae
• Impression: Cardiomegaly with congestive
pulmonum Right-left pleural effusions
(dominant left) Thoracal spondylosis
BOF (26/9/18)
• no visible abdominal distension, pre-left peritoneal fatline is
firm
• Multiple radioopaque shadows on the pelvic cavity
• Does not appear coiled spring appearance, herring bone sign
or signs of free air
• Normal intestinal gas distribution
• The contour of the right and left kidney does not appear
clear.Psoas line left and right does not appear clear
• The shadow of the liver and spleen does not appear enlarged
• Osteophyte appear on VL 1-5, pedicle and intervertebral
spatium are good

• Impression: Susp Multiple bladder stone stone. There were

no signs of ileus or pneumoperitonium Lumbar spondylosi
 Assessment

ACKD ec post renal on CKD ec susp NO.

• Hyperkalemia
• Mild anemia normochromic normositer
• Gastropati urekum
Invasif urothelial Ca
 VI. Planning
Therapy Monitoring
• HD Cito •Vital sign
•Complaint
• O2 3lpm via nasal canule
•BUN/SC, Na/K every 6 hour
• IVFD D5% 20tpm •Blood sugar every 1 hour
• Ca Gluconos 3x1gr IV •CaPo4 anorganik and uric acid

• Insulin aspart 20unit +100cc D10% + 100 cc D40% habis dalam

30 menit
• Domperidon 3x10mg
• Monitoring post HD