morning report 10 maret 2013 sn

7/28/2019 Morning Report 10 Maret 2013 SN

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Departement of InternistPavilion Marwah, 10th March 2013(14.00- 07.00 am)


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Identity

Name : Mr. K Age : 35 YO

Religion : Moeslim

Date : 10 March 2013 No. MR : 19.54.19


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Anamnesis

Chief complaint: abdominal pain Present illnes: Patient complained about his abdominal

pain since 2 month before hospitalized. He felt nausea

(+), vomit (-), abdominal discomfort (+), fever (-).

Patient also complained about his swollen leg since 3month ago. But the patient didnt know which part of

the body get swelling first. Patient also complained

about pain in his waist. This pain could reduce by

drinking water.


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History or past illness :

- He had history of hypertension and gastritis.

- Hypercholesterol and diabetes denial

- History of liver disease (-)

History of family (-)

History of sociality:

- Herbal medicine, coffee, soft drinks and energy drink

consumption (+)


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Physical Examinations

General Appearance : weak

GCS : 456

Vital sign :

BP : 145/100 mmHg

Pulse : 112 bpm

RR : 26 x/minutes

T : 38 C


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Physic Examinations

Head and neck :

Anemic -/icteric-/cyanosis-/dyspneu-, edema palpebra(minimal)

Thorax :

I : simetric bilaterally +, retraksi -/-P : ICS normal

P : sonor/sonor

A : ves/ves, rh-/-, whz-/-RR : 22x/minute, spontan

Cor : S1 S2 single, M-, G-


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Abdomen :

I : distended, mass (-)

P : Soefl, tenderness (-), Murphy sign (-)P: Tymphani (+)

A : Bowel Sound (+) Nomal, Met (-)

Extremity :Dry and warm to touch

CRT< 2 detik

Pitting edema +


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Albumin 1,2 mg % (3,5 5,5 mg%)

Globulin 3,0 gr % Total protein 4,2 mg% (5,8-8,7

mg%)

Clorida serum 104 (70-108 mol/l)

Kalium serum 3,2 (3,6-5,5 m mol/l)

Natrium serum 133 (135-155 m

mol/l)

Urea 39 mg/dl

Serum creatinin 0,9 mg/dl

Uric acid 5,1 mg/dl

Diff count: 0/0/91/8/1

Hematocrite: 36,6 % Hb 12,1 mg/dl

LED : 96/98

Leukocytes : 16.900

Thrombocyte : 365.000

HBs-Ag Negatif

Alkali phospatase : 138 U/L

Bilirubin direk : 0,11 mg%

Bilirubin total 0,30 mg%

SGOT/SGPT : 30/21 U/L

Laboratory Findings


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Photo Thoraks


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USG Abdomen


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Man, 35 year-old Abdomnal pain, nausea (+), vomit (-), abdominal discomfort

(+), fever (-)

Body swelling

Pain in his waist and reduce by drinking water

Herbal medicine, coffee, soft drinks and energy drinkconsumption (+)

Chest x-ray : efusi pleura bilateral

USG abdomen : Nephritis acuta bilateral, Ascites, Efusi pleura

bilateral

Clue and cue


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Suspect Nephrotic syndrome + sekunder infection

Pleural effusion bilateral

Assessment


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Planning Dx : UL

Profile lipid

Planning Tx : O2 nasal 2 lpm

Pasang DC

Infus Asering 1000cc/24h

Inj. Antrain 3x1

Inj. Methylprednisolone 1x125mg

Inj. Ranitidin 2x50 mg

Inj. KCl 25 meq/12jam

Inj. Ceftriaxone 2x1

c/ internist

Planning


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Prognosis

Dubia ad bonam

Education

Explain to the family about the condition of this

patient now, its disease, about its

examinations, theraphy and intervention will

be done, and also about complication and

prognosis.

morning report 10 maret 2013 sn

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