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1( Dr.

Etik)
Morning Report
Saturday, February, 9th, 2013
Moderator :
Physician In Charge:
IA : dr. Etik, dr. Arya, dr. Ali (cardio)
IB : dr. Fajar, dr. Sigit
II : dr. Didin
III : dr. Rulli Rosandi, Sp.PD
Summary Of Database:
Male/50 yo/W 26
Chief Complaint: Shortness of Breath
Patient suffered from shortness of breath since 3 days prior to hospital. It worsened a day before
admission untill he cant did his daily activity. He didnt suffered from cough. Patient suffered from
nausea and vomiting since 3 months ago, worsened in 3 days, frequency 10x/day, volume glass
contained of water and residual food. He felt decreased of appetite since 3 days ago about 3
spoon/meal. The passing urine was decreased, but passing stool and flatus may normally. He was
also felt dizziness since 1 month ago especially after he vomited.
History of past illness: He had Hypertension since 4 years ago, unroutinely controlled. The blood
pressure was 200/... He ever hospitalized at Purwodadi Hospital and diagnosed as kidney disease
and then refers to RSSA for HD. DM is denied.
Family History: No one in family that had kidney disease.
Social History: Patient is a farmer and he routinely consume traditional potion for body pain since
last 2 years.
Physical Examination
BP= 230/120
PR= 92 bpm (ER)
mmHg (ER)
88 bpm regular
180/120 mmHg
strong
General App.: looked moderately ill
Head
Neck
Thorax

Abdomen
Extremities

RR = 32 tpm (32)
20 tpm

Ax. Temp.= 37.3 0C

GCS : 456
Looked normoweight
Icteric sclerae (-)
Edema palpebra (+)

Anemic conjunctiva
(+)
JVP : R + 4 cm H2O; 300, Lnn enlargement (-)
Cor
Ictus visible, palpable at ICS V, MCL S
RHM SL D
LHM ictus
S1, S2 single, murmur -/Pulmo
Symmetric; SF D=S; S| S
V |V
Rh
+| Wh
-|S| S
V |V
+|+
-|S| S
V |V
+| +
-|After HD Rh -/Flat, BS (N), Liver span 8 cm, traubes space tymphani, shifting
dullness(-)
Edema -/-

LABORATORY FINDINGS

2( Dr. Etik)
LAB

RESULT

Leukocyte

6360

Hemoglobine

7.7

MCV
MCH
PCV
Thrombocyte

81.5
27
22.5
80.000

SGOT

25

SGPT
Diff count
Eos/Ba/Neu/Ly/Mo

31
2.4/0.3/73.4/17.0/
6.3

NORMAL
VALUE
3,50010,000/L
11.0-16.5 g/dl

LAB
Sodium
Potassium

80-97 m3
26.5-33.5 m3
35-50%
150,000500,000/l
11-41U/L

Chloride

10-41U/L

PPT
APTT

RBS
Ureum
Creatinine
eGFR MDRD

RESULT
135 138
5.14
-3.63
108 -105

NORMAL
VALUE
136 145
3.5 5.0
98 - 106

108 - 110
290.4
138.6
15.94
7.16
3.4 (pre
HD)

< 200
16.6 48.5

10.4
25.6

11.5
28.1

< 1.2

UL : not yet performed after HD


BGA:
pH
7.29
pCO2 31.7
pO2
163
HCO3 16.5
SaO2 98.9%
BE
-11.6
True O2 : 38.2
Conclusion: Metabolic acidosis uncompensated
CXR after Furosemid injection :
AP position, enough inspiration, KV enough, symmetric, trachea in the middle, bone and soft tissue
normal, Phrenicocostalis angle D/S sharp, Hemidiaphragm D/S domeshape, Pulmo : BVP increasing ,
Cor: site normal, size CTR < 50%, and shape normal.
Conclusion : Normal Chest X Ray
ECG:
Sinus rhythm HR 78 bpm, Frontal axis normal, Horizontal axis normal, PR interval 0.12, QRS
complex 0.12, QT interval 0.36. Tall T at lead V2-V5. Conclussion : Sinus Rhythm with HR 78 bpm
and Hyperpotassemia.

CUE&CLUE
Male, 50 yo
Shortness of
breath
Nausea and
vomiting
Decreased of
appetite
HT unroutinely

PL
1.SOB

IDx
1.1 Non
Cardiogeni
c
1.1.1 Uremic
Lung
1.1.2 Pneum
onia
CAP

PDx

PTx
O2 8-10 lpm NRBM
HD cito
Drip GTN 10 mkg/mnt
Inj. Furosemid 60 mg
continue with
Furosemide 3x40 mg iv

PMo
S
VS
Dehydratio
n sign

3( Dr. Etik)
controlled
PE :
An(+)
BP 230/120
PR 92
RR 32
Rh +/+

1.2 Cardiogeni
c
1.2.1 HT
emerge
ncy

Male, 50 yo
Shortness of
Breath
Nausea and
vomiting
Hypertension
since 4 years
unroutinely
controlled
Routinely
consume
traditional
potion
PE :
An (+)
BP 230/120
PR 92
RR 32
Rh +/+
Lab :
Kalium 5.14
Ureum 290.4
Creatinin
15.94
eGFR 3.4
Asidosis
Metabolic
uncompensate
d
Male, 50 yo
Decreased of
apetite
PE :
An(+)
Lab :
Hb 7.7
MCV/MCH :
81.5/27

2. CKD st V

2.1
Hypertension
Nephrosclerosi
s
2.2 NSAID
Gastropathy

Kidney Biopsi

Balance fluid negative


IVFD NS 0.9% 20 tpm
Renal diet: 1900Kcal/d;
Low salt<2gr/d; protein
1-1.2 gr/KgBW/day, low
potassium
HD

S
VS

3. Anemia
Normochrom
Normocyter

3.1 due to no
2
3.2 Chronic
Inflammation

Blood Smear

S
VS
Hb Level

count

Plan to give
Eritropoeitin
PRC transfussion until
Hb 10 gr/dl

Male, 50 yo
History of
hypertension
since 4 years
ago
unroutinely
controlled
BP : 230/120

4.
Hypertension
Emergency

3.1 Primary
3.2 Secondary

Funduscopy

Drip GTN as above

S
VS

Reticulosyt

4( Dr. Etik)