Post on 25-Nov-2014
transcript
Morning Report
7th February 2011
Identity
Name : NNB Age : 84 y.o.Gender : femaleEthnicity : BalineseReligion : HinduMarital status : marriedAddress : Br. Dangin Jalan,
GuwangMR No. : 01.42.36.79Time of admission : 14.40 WITA
AnamnesisChief Complaint: breathlessness
Present history:
• The patient complained of
breathlessness since 3 days BATH,
appeared gradually and became worse
in the morning before she came to
hospital.
• The complaint was felt continously, not
affected by changing position
• Also complained weakness of the body since 1 weeks, gradually worsen
• Cough (-), fever (-), nausea (-), vomiting (-)
• Urination (+) but decrease in amount, yellowish colour, urinating pain(-), stone (-)
• Defecation (+) normal
Past history:• Patient had kidney disease and
urinary tract stone known since 3 months ago.
• Asthma (-), DM (-), HT (-), allergic (-)
Medication history:• Hemodialysis 3 months ago c.b.
kidney disease
Family history: • None of the patient’s family
members had similar complaints or diseases
Daily habits: • The patient denied any history
of using tobacco and alcohol consumption
• Patient was a housekeeper, helping her doughter in law cooking or making “canang”
Physical Examination
General appearance : moderately ill
GCS : E3V5M6BP : 110/50 mmHgRR : 28 x/minPR : 84 x/mintax : 36,7°C
BW : 60 kg
Eyes : anemia (-/-); icterus (-/-); pupillary reaction +/+ isocoric; palpebral edema +/+
ENT : no abnormalities foundNeck : no abnormalities foundThorax : simetric
Heart◦ Inspection : ictus cordis not visible◦ Palpation : ictus cordis not palpable ◦ Percussion : UB: ICS II, RB: PSL D, LB: 2 fingers left to
MCL S◦ Auscultation : S1S2 single regular murmur (-)
Lungs◦ Inspection : symmetrical, retraction (-)◦ Palpation : tactile fremitus N/N◦ Percussion : sonor/sonor◦ Auscultation : vesicular +/+; ronchi +/+; wheezing -/-
Abdomen– Inspection : distention (-); ascites
(-)– Auscultation : bowel sounds (+)
normal– Percussion : tymphani– Palpation : tenderness on palpation
(-); liver & spleen not palpable; ballotement +/-
Extremities : warm (+); edema (+)
Laboratory ExaminationsComplete Blood Count (CBC)
Parameter Result Unit Reference range
Interpretation
WBC 9,51 103/μL 4,1 – 10,9 Normal
-Ne 7,59 103/μL 2,5 – 7,5 Normal
-Ly 0,88 103/μL 1,0 – 4,0 Normal
-Mo 0,898 103/μL 0,1 – 1,2 Normal
-Eo 0,110 103/μL 0,0 – 0,5 Normal
-Ba 0,040 103/μL 0,0 – 0,1 Normal
RBC 2,13 106/μL 4,00 – 5,20 Low
HGB 6,48 g/dL 12,00 – 16,00 Low
HCT 19,3 % 36,0 – 46,0 Low
MCV 90,8 fL 80,0 – 100,0 Normal
MCH 30,4 pg 26,0 – 34,0 Normal
MCHC 33,5 g/dL 31,0 – 36,0 Normal
RDW 15,6 % 11,0 – 14,8 Normal
PLT 149 103/μL 150 – 440 Low
MPV 8,95 fL 0,0 – 100,0 Normal
Blood Chemistry Panel
Parameter Result Unit Remarks
Reference range
SGOT 18,89 U/L Normal 11,00 – 33,00
SGPT 9,66 U/L Low 11,00 – 50,00
Total Protein
6,968 g/dL Normal 6,40 – 8,30
Albumin 2,927 g/dL Low 3,40 – 4,80
BUN 106,5 mg/dL High 10,00 – 23,00
Creatinine 8,843 mg/dL High 0,50 – 1,20
• GFR : 4,4
Blood Gas Analysis
Parameter Result Unit Remarks
Reference range
pH 7,03 - Low 7,35 – 7,45
pCO2 18,0 mmHg Low 35,0 – 45,0
pO2 165,0 mmHg High 80.0 – 100,0
Hct 19,0 % Low 37,0 – 49,0
HCO3- 4,8 mmol/L Low 22,0 – 26,0
TCO2 5,4 mmol/L Low 24,0 – 30,0
BE(B) -23,8 mmol/L Low -2 – 2
SO2c 99,0 % 95,0 – 100,0
THBc 5,9 g/dL Low 13,0 – 18,0
Natrium 135,0 mmol/L 135,0 – 145,0
Kalium 4,4 mmol/L 3,4 – 4,8
X-Ray (Thorax AP)
• CTR : 54 %• COR : enlargement (-),
cardiac waist (+)• Po : infiltrate (-),
nodule (-), bronchovascular pattern rising
• Sinus pleura : Left & Right sharp
• Diaphragm : Left & Right normal
• Bones : fracture humerus sinister proximal.
• Conclusion : uremic lung
X-Ray (Plain Abdomen)
• Radioopaque at right ureter
• Interpretation: suspect ureter stone dexter
USG (Oct, 9, 2010)
USG (Oct, 9, 2010)
• Hydronephrosis Grade III Dexter ec. Post Renal
• Bilateral Nephritis• Plural Efusion
Assessment
• CKD stage V c.b. Susp. PNC d.d. NO- Uremic lung- Hydronephrosis grade III dexter- Uremic encephalopaty - Ureter stone dexter- Metabolic acidosis- Moderate anemia N-N
• Hipoalbumin (2,9) c.b. chronic inflamation
PlanningTherapy• Hospital admission• IVFD NS 8 dpm• Dietary 35 kcal + 0,8 gr protein/kgBW• O2 8 lpm• CaCO3 3 x I• Folic acid 2 x II• Tranfusion PRC 2 kolf• Hemodialysis• Natrium bicarbonat bolus 50 ml drip
75 mg in D5% 500 ml
Planning Diagnostic :• Urinalysis• USG abdomen
Monitoring :• Vital Signs• Complaints • BGA @ 6 h
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