Beruflich Dokumente
Kultur Dokumente
th
Moderator :
Physician In Charge:
IA : dr. Herman, dr. Anshory, dr. Greg (cardio)
IB : dr. Yuni, dr. Rifai
II : dr. Hidayat
III : dr. Bogi, Sp.PD-KGEH
Summary Of Database:
Mr Suwandi/51 Y.O/W 24A
Physical Examination
0
Flat, BS (N), liver span 7 cm, traube space tympany, flank pain D/S -, suprapubic pain -,
soft, epigastric tenderness (+)
Edema (+), dry texture
2( Dr. Herman)
LABORATORY FINDINGS
LAB
RESULT
Leukocyte
7.360
NORMAL VALUE
3,500-10,000/L
LAB
Sodium
RESULT
132
NORMAL VALUE
136-145 mmol/l
Hemoglobine
9.10
11.0-16.5 g/dl
Potassium
6.16
3.5-5.0 mmol/L
MCV
MCH
91.60
29.40
80-97 m3
26.5-33.5 m3
Chloride
110
98-106 mmol/L
PCV
28.30
35-50%
RBS
109
>200 mg/dL
Thrombocyte
252,000
150,000-
Ureum
171.30
10-50 mg/dL
390,000/l
SGOT
31
11-41U/L
Creatinine
9.10
0.7-1.5 mg/dL
SGPT
31
10-41U/L
Albumin
3.73
3.5-5.5 g/dL
Diff count
2.0/0.8/65/19.3/12.6
GFR MDRD
6.55
ml/m /1.73 m
Eos/Ba/Neu/Ly/Mo
ECG:
Sinus rhythim, HR : 90 bpm
PR interval
: 0,16
QRS complex
: 0,08
QT interval
: 0,34
Frontal Axis
: LAD
Horisontal Axis
: clockwise rotation
S persistent V5-V6
Conclusion : sinus rhytim, HR 90 bpm, RVH
CUE&CLUE
Male/51 y.o
Nausea vomiting
Decrease appetite
Diagnosed CKD
and undergo HD
PL
1. Nausea and
Vomiting
IDx
1.1 Uremic
Gastropathy
1.2 Gastritis
Erosiva
PDx
Endoscopy
PTx
Metoclopramide 3x10 mg iv
Ranitidine 2x50 mg iv
Elective HD
PMo
S
VS
Dehydration
sign
3( Dr. Herman)
routine
Epigastric pain +
Male/51 y.o
Nausea and
vomiting
Decrease appetite
Leg swelling
HT since 1 year
ago
Stone removal
surgery 1 year
ago
Diagnosed CKD
and undergo
routine HD
BP 181/111, PR
89, RR 18, T 36.5
C
Ictus invisible,
palp at ICS VI 1
cm lat lat MCL S
Hb 9.10, MCV
91.60, MCH 29,40
K 6.16
Ur/Cr 171.30/9.10
eGFR 6.55
cxr: cardiomegaly
ECG: RVH
2. CKD St 5 on HD
2.1 Obstructive
Uropathy
2.2 Hypertension
Nephrosclerosis
Male/51 yo
Diagnosed CKD
K 6.16
3.
Hyperpotassemia
3.1 due to No 2
Male/51 y.o
-Diagnosed CKD
- Hb 9.10
-MCV 91.60, MCH
29.40
Male/51 yo
History of HT and
CKD
BP: 181/111
mmHg
4. Anemia
Normochrom
Normocytair
5. Hypertension St
II
Male/51 y.o
Leg swelling
HT since 1 year
ago
Stone removal
surgery 1 year
ago
Diagnosed CKD
and undergo
6. HF St C Fc 1
5.1 secondary
5.1.1
renoparenchymal
hypertension
5.1.2
renovascular HT
5.2 primary
6.1 uremic
cardiomyopathy
6.2 HT
cardiomyopathy
6.3 HHD
6.4 Anemic heart
disease
Kidney Biopsy
S
VS
UOP
Ca gluconas 1000 mg
Rapid acting insulin 10 iu
D40% 50 cc
Ferritin serum,
blood smear,
reticulocyte
count
S
VS
Hb
Funduscopy
Diltiazem 2x30 mg
Clonidin 3x0.15 mg
S
VS
Target organ
damage
Lipid profile,
Echocardiograph
y, Uric acid
Antihypertension as above
S
VS
4( Dr. Herman)
routine HD
BP 181/111, PR
89, RR 18, T 36.5
C
Ictus invisible,
palp at ICS VI 1
cm lat lat MCL S
Hb 9.10, MCV
91.60, MCH 29,40
K 6.16
Ur/Cr 171.30/9.10
eGFR 6.55
cxr: cardiomegaly
ECG: RVH