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    Morning Report Case: 24 April, 2012

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    Renata Yolanda
    This document contains a morning report case summary for a 56-year-old Balinese Hindu male patient who presented with complaints of epigastric pain for the past 3 days along with nausea and vomiting. The physical examination revealed tenderness in the epigastric region and laboratory results showed abnormalities including elevated kidney function tests and anemia. Radiological imaging detected radiopaque objects in the urinary bladder and right ureter. The assessments were chronic kidney disease stage 5, suspected non-drug-defined peptic ulcer disease, gastroparesis uremicum, moderate anemia, suspected urinary bladder and right ureter stones, and hypertension. The treatment plan included hospitalization, intravenous fluids, medications, hematology

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    Morning Report Case: 24 April, 2012

    Uploaded by

    Renata Yolanda
    29 views20 pages
    This document contains a morning report case summary for a 56-year-old Balinese Hindu male patient who presented with complaints of epigastric pain for the past 3 days along with nausea and vomiting. The physical examination revealed tenderness in the epigastric region and laboratory results showed abnormalities including elevated kidney function tests and anemia. Radiological imaging detected radiopaque objects in the urinary bladder and right ureter. The assessments were chronic kidney disease stage 5, suspected non-drug-defined peptic ulcer disease, gastroparesis uremicum, moderate anemia, suspected urinary bladder and right ureter stones, and hypertension. The treatment plan included hospitalization, intravenous fluids, medications, hematology

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    MR ckd

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    This document contains a morning report case summary for a 56-year-old Balinese Hindu male patient who presented with complaints of epigastric pain for the past 3 days along with nausea and vomiting. The physical examination revealed tenderness in the epigastric region and laboratory results showed abnormalities including elevated kidney function tests and anemia. Radiological imaging detected radiopaque objects in the urinary bladder and right ureter. The assessments were chronic kidney disease stage 5, suspected non-drug-defined peptic ulcer disease, gastroparesis uremicum, moderate anemia, suspected urinary bladder and right ureter stones, and hypertension. The treatment plan included hospitalization, intravenous fluids, medications, hematology

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    29 views20 pages

    Morning Report Case: 24 April, 2012

    Uploaded by

    Renata Yolanda
    This document contains a morning report case summary for a 56-year-old Balinese Hindu male patient who presented with complaints of epigastric pain for the past 3 days along with nausea and vomiting. The physical examination revealed tenderness in the epigastric region and laboratory results showed abnormalities including elevated kidney function tests and anemia. Radiological imaging detected radiopaque objects in the urinary bladder and right ureter. The assessments were chronic kidney disease stage 5, suspected non-drug-defined peptic ulcer disease, gastroparesis uremicum, moderate anemia, suspected urinary bladder and right ureter stones, and hypertension. The treatment plan included hospitalization, intravenous fluids, medications, hematology

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 20

    MORNING REPORT CASE

    24th April, 2012

    PATIENTS IDENTITY
    Name Age Gender Ethnicity Religion Address MR Tc : IWL : 56 yo : male : Balinese : Hinduism : Selat,Karangasem : 01.55.66.67 : 16.05

    ANAMNESIS

    Chief complain :

    pain in the epigastrium Present history : Patient complained of pain in the epigastrium since 3 days BATH. The pain suddenly appeared and presist. The pain feel like pricked by needle. And it made patient couldnt do his daily activities.

    He

    also complained of nausea and vomiting since 3 days BATH. Two times vomiting, each time throwing up half of mineral water glass. Contain : food and water. History of fever 5 days BATH, but at this time he didnt got fever anymore History of pain when urinate, history of decrease in volume of urine was denied by the patient.

    Past illness history


    History

    of pain in the epigastrium like this before was denied by the patient. The patient had a history of hypertension since 3 months ago but did not routinely control to health centers. Patients previously treated in Karangasem hospital for the same complaint. Then referred to Sanglah for further treatment. No history of using drug for long time medication.

    Family history :
    None

    of the family member had the same complained as the patient History of HT and DM was denied

    PHYSICAL EXAMINATION
    General appearance : Moderately ill Level of consciousness : CM Vital Sign: BP RR HR tax Bw Bh BMI

    : 140/90 mmHg : 20 x/min : 78 x/min : 36,6C : app 65 kg : app 165 cm : 24,07

    Eyes

    : anemis(+/+); icterus (-/-); Rp +/+ isocoric, oedema palp. (-/-)

    ENT : Tonsils T1/T1; pharyngeal hyperemia (); tongue normal; lip cyanosis (-) Neck : JVP RP + 0 cmH2O; lymph node enlargement (-)

    Thorax : Simetris, retraction (-) Cor Inspection : Ictus cordis unseen Palpation : Ictus cordis unpalpable Percussion : UB : ICS II LB : at MCL S ICS V RB : at PSL D Auscultation : S1 S2 single regular, murmur (-) Po Inspection : Symetric (static and dinamic) Palpation : VF N/ N Percussion : sonor/sonor Auscultation : vesikular + / + , Rh -/-, wh -/-

    Abdomen : Inspection Auscultation Percussion CVA (-) Palpation in spleen not

    : Distention (-); ascites (-) : Bowel sounds (+) normal : Tympani, knock pain in : Tenderness on palpation epigastrium (+); liver& palpable Ballotment (-/-)

    Extremities: Warm +/+; edema -/-

    Complete blood count


    Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT MPV 59,10% 24,6% 8,4% 7,70% 0,20% 2,40 7,90 22,20 92,80 32,9 35,50 12,30 242,00 5,3 Result 4,70 2,80 1,20 0,40 0,00 0,00 Unit 103/L 103/L 103/L 103/L 103/L 103/L 106/L g/dL % fL pg g/dL % 103/L fL L L L L Remarks Reference range 4,5 11,00 47,00 80,00 13,0 40,0 2,00 10,00 0,00 5,00 0,0 0 2,00 4,50 5,90 13,50 17,50 41,00 55,00 80,00 100,00 26,00 34,00 31,00 36,00 11,60 14,90 150,0 440,0 6,80 10,00

    Blood chemistry panel


    Parameter SGOT Result 26,3 Unit U/L Remarks Reference range 11,00 33,00

    SGPT
    BUN Creatinine

    14,4
    98,0 11,52

    U/L
    mg/dL mg/dL mg/dL mg/dL H H H

    11,00 50,00
    10,00 23,00 0,50 1,20 136-145 3,5-5,1

    eGFR
    Na K

    7,36
    124 3,8

    Urinalysis
    Parameter
    pH Leucocyte Nitrite Protein Glucose Ketone Urobilinogen Bilirubin Erytrocyte Spesific Gravity Colour SEDIMEN URINE Leucocyte Erytrocyte Silinder Others 1-2 2-4 Bactery (+) /lp /lp /lp /lp <6/lp <3/lp -----

    Result
    5,00 25,0 Neg 25,0 norm neg norm neg 50,00 1,01 p. Yel

    Unit
    Leu/uL mg/dL mg/dL mg/dL mg/dL mg/dL ery/uL -

    Remarks

    Reference range
    58

    +1 neg +1 +2 Neg Neg neg +5

    Negative Negative Negative Normal Negative 1 mg/dl Negative Negative 1,005 1,020

    p.yel

    p. yellow - yellow

    Ro. Thorax
    Cor : CTR 48% Pulmo : infiltrate (-) Sinus prenicus sharp Diaphragma normal conclusion : Normal

    BOF
    Radioopaque appearance (+) Urinary bladder , Right ureter

    ECG

    Sinus rhytm Axis normal HR 76 x/min ST-T change (-

    LVH (-)

    ASSESMENT

    CKD st V susp NO dd/PNC - Gastropati Uremicum -moderate anemia NN on CKD Susp urinary blader stone and ureter stone (Right) Hiponatremia Hypertention ST I

    TX

    Hospitalize Ivfd 8 tpm Omeprazole 2x40mg (IV) Domperidon 3 x 10 mg tb (PO) Asam folat 2x2 tab CaCo3 3x1 tab Captopril 2x 25 mg HD elektif

    Pdx
    USG

    Urologi SI,TIBC,feritin Consult to urologist

    Monitoring
    Vital

    sign Complaints

    THANK YOU

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