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MORNING REPORT

Doctor in charge:

Dr. Enita Rakhmawati K, M.Sc, Sp.PD

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PATIENT’S IDENTITY

Name : Mr. Syahran

Sex : Male Age : 69 yo

Occupation :

Hospitalised since : April 7th 2016

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SUMMARY OF DATA BASEMr S./63 y.o/ Male/ Heteroanamnesis

Patients complain of Shortness of breath . Patient also had blood in his

urine for three days. Patient had history CKD stage 5 pro HD for Five years.

Patient also have history of Cancer in urine bladder before he had CKD and

pro chemotherapy . Patient had routine hemodyalisis.

Patient have history of hyperkalemia that have been corrected.

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PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION

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Items Result Normal Value Unit

Gran% 74,3 50,0-70,0 %

Limfosit% 14,1 25,0-40,0 %

MID% 11.6 4,0-11,0 %

Limfosit# 1,1 1,25-4,0 thousandu!

Gran# 5,"0 2,50-7,00 housandu!

MID# 0,$ thousandu!

a!ium 3,0  3,4-5,4

Hasil PT 34,9 9,9 – 13,5

Hasil APTT 42,4 22,2 – 37,0

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LABORATORY RESULT 6/04/2016

Items Result Normal Value UnitHematology

Hemoglobine 7,1 12.00 - 15.60 g/dl

Leukocyte 7," 4.65 & 10.3 thousand/ul

Eritrocyte 2,$4 4.00 & 5.30 million/ul

Hematocrit 24,4 37.00 & 47.00  Vol%

Trombocyte 777 150 & 356 Ribu/ul

'D(-)* 17,2 12.1-14.0 %

MCV "3.3 75.0 & $6.0 Fl

MCH 26,5 2".0 & 32.0 Pg

MCHC 31,$ 33.0 & 37.0 %

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JAM 14.51

GDS 103

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Problems Data support

1.Hematuri

1.1 Ca buli on kemo

 Ax: Riwayat Ca Buli

Px : Nyeri palpasi

-/-/-

-/-/-

-/+/-2. Sesak

2.1 CKD stage 5 pro hd

3. Hipertensi stage 1

3.1 Primary

3.2 Secondary

4. Anemia N-N

4.1 Chronic disease

x: Sesak (+) Riwayat CKD st 5

Lab : Ur/Cr meningkat

Hiperkalemi

TD 140/70

Hb 98

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Problems PDx PTx PMo Ped

1. Ca buli on kemo Konsul

Urologi

DL, Ur/Cr,

SE

funduskopi

DL

Konsul Urologi

IVFD Nacl 0,9 20 tpm

Diet GinjalNexium

P.o candesartan 16mg 0-

0-1

 As. Folat + Besi Oral

Kateter threeway

Monitoring

SEUr/Cr

Mo. TTV

DR

RestriksiCairan

2. CKD stage 5 pro hd

3. Hipertensi stage 1

3.1 Primary

3.2 secondary

4. Anemia N-N

4.1 Chronic disease

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Thank you