MORNING REPORT

Tuesday, desember 11 2012

Coass in charge:
Firman Kurniawan Arisandy
Ayu Sekarani D.P
Moderator:
Dr.Didi Chandra, Sp.PD KPTI

Summary of Data Base

Mr.H/ 32 y.o/ W 26
Chief Complain : Epigastric pain
The patient suffered from epigastric pain, nausea, and vomitting since
yesterday. He vomited 5 times in a day, just water. He suffered decreased
of appetite since 3 weeks ago, just ate 2 times a day 4-5 sponfull of rice.
His complained followed general weakness since a week ago
He suffered from both legs swelling since 2 weeks ago. He Sleep with
2 pillows because when sleep with 1 pillow he felt SOB. Lately, patient
ussually felt SOB when walking. Patient often woke up in the night
because shortness of breath since a month ago.

He had history drank traditional potion once a

week for 2 years. He drank it for his all body pain.
The traditional potion was jamu pegel linu. He
has been worked as a foreman at bali since 2
months ago and he went back to the java since
he felt his body swelling especially his leg
History of DM (-). Since a year ago, patient known
that he had hypertension but Px not routinely
controled and not tooked medicine.
BAB and BAK in the normal limit

Physical examination
BP = 170/100mmHg

PR = 85 bpm
strong reguler

RR = 24 tpm

Tax : 37,6 C

General appearance looked severely ill

GCS 456; Compos mentis, Looked

normoweight

Head

Anemic +/+

Icteric -/-

Neck

JVP R + 3 cm; 30

Thorax:

Cor:

Lung:

Ictus invisible and palpable at 2 cm lateral MCL ICS VI Sinistra

RHM SL Dextra
LHM ictus
S1, S2 single with no murmur,
Symmetric, SF D = S, v v
vv
vv

No additional breath sound

Abdomen

Flat, soefl, liver span 8 cm, troube space tympani, shiffting

dullness (-)

Extremities

Warm, Leg pitting edema +

Laboratory finding
Lab

Value

Lab

Value

Leukocyte

9890

3.50010.000/L

Natrium

132

136-145 mmol / L

Haemoglobine

5,8

11,0-16,5 g/dl

Kalium

6,96

3,5-5,0 mmol / L

MCV

83,30

Chloride

112

98-106 mmol/L

MCH

28,40

PCV

17

35-50%

Trombocyte

201.000

150.000390.000/L

RBS

116

SGOT

13

11-41U/L

Ureum

435,60

10-50 mg/dL

SGPT

10-41U/L

Creatinine

31,38

0,7-1,5 mg/dL

Laboratory Finding
BGA

Value
(Suplemental O2 4 Lpm)

PH

7, 16

7,35-7,45

PCO2

12,7 mmHg

35-45

PO2

105,6mmHg

80-100

HCO3

4,6 mmol/ l

21-28

O2 saturation

96,6 %

> 95%

Base Excess

-23,3

-3 until +3

Conclussion

Acidosis Metabolik partially compensated

ECG
Sinus rhythm, Heart rate 100bpm
PR interval
:0,12''
QRS complex : 0,08
ST interval
:0.30
Frontal Axis
: Normal
Horizontal Axis : Normal
Conclusion : sinus rhythm, heart rate 100
bpm

CXR
AP position, asymetric, enough KV, enough
inspiration
Trachea in the middle
Soft tissue and bone normal
Hemidiaphragma D and S dome sharp
Phrenico costalis angke D/S sharp
Cor site and shape are normal, CTR: 60%
Conclusion:
Cardiomegaly CTR>60%

CUE AND CLUE

PL

IDx

PDx

Mr.H/32yo/W26
He has been
consumining
traditional potion
once a week for 2
years.
Hipertensional
known when
admission
Leg swelling
since 2 weeks ago
Nause, vomiting
Pale skin and
general weakness

1. CKD
stage
V
Newly
diagno
se

1.1. NSAID
Nephropath
y
1.2. HT
nefrosklero
sis

USG
Abdome
n

PE
Conj. Anemis +/
+
Leg edema +/+
Lab
Anemia NN: 5,8
Ur/Cr:
435,6/31,38
eGFR: 1,73
K: 6,96
BGA: asidosis

PTx
O2 8-10 Lpm (NC)
Semiflower position
Iv plug
Fluid balance negatif
500-1000 cc/hr
Low protein diet 1900
kcal/day (0,60,8g/kg/day), protein 0,50,8 gr/day, RG<2gr/day
Inj Furosemide 40-4040(iv)
p/o :Nifedipine 1 x 10 mg
HD Cito

PMo
Subje
ctive
VS
DL
UL
Ur/Cr
Urine
produ
ction

CUE AND CLUE

Mr.H/32yo/W26
Epigastric pain,
nausea, vomiting
Has CKD
diagnosed when
admitted

PL

IDx

2.
Asidosi
s
metab
olik

3.Hype
rkalem
ia

PDx

PTx

PMo

2.1 dt No 1

Bolus 100 meq nabic iv

slowly
Drip 100meq nabic
dalam 500 cc NS 0,9% 10
tpm mikro

VS,
Subj,
SE
BGA

3.1.due to
No.1

Ca gluconas 1amp (slow

iv)
Bolus D40% 50mL (iv)
Actrapid 10iu (iv)

VS,
Sunj,
GDA,
SE 4
hr
post
corre
ction

PE
RR:24tpm
BP: 170/95
BGA: Asidosis
metabolik
Egfr:3,46

Mr.H/32yo/W26
Has been
diagnosed CKD
when admitted
K: 6,96

CUE AND CLUE

PL

Mr.H/32yo/W26
4.HF st
C Fc IV
Shorthness of
Breath
DOF since a week
ago

IDx

PDx

PTx

PMo

4.1. Uremic Electroc

Cardiomyop ardiogra
athy
phy
4.2.HHD

As above (Furosemide)

Subje
ctive
VS

BP: 170/95
mmHg
CXR
:cardiomegaly
Mr.H/32yo/W26
BP:170/95mmHg

5.HT
st. II

5.1
Secondary
HT
5.2 Primary
HT

Fundusc
opy

As above (Inj Furosemide

40-40-40(iv) and
Nifedipine 1 x 10 mg

Subje
ctive
BP

Mr.H/32yo/W26
Pale skin, nausea
vomiting, general
weakness.
Diagnosed CKD
when admitted

6.Ane
mia
normo
chrom
normo
cyter

6.1.due to
No.1

Ferritin
Serum

PRC transfusion 1
pack/day until Hb8gr/dL
EPO inj 50 iu/kgBB iv 3
times a week

Hb

Lab
Hb: 5,8
MCV : 83,30

CUE AND CLUE

PL

Mr.H/32yo/W26
Nausea and
vomiting
Epigastria pain
History of
traditional potion
once a week for 2
years

7.Dysp
epsia
syndro
me

eGFR:3,46

IDx
7.1.Uremic
gastropathy
7.2.NSAID
gastropathy

PDx

PTx

PMo

Endosc
opy

Omeperazole2x20mg (iv)

Subje
ctive
BP
HR
RR
Hb

THANK YOU