MORNING REPORT

February 19th 2014

STUDENTS IN CHARGE: ROSANDY FEBRIANTO NINDY TJIONGANATA

SUPERVISOR : Prof.Dr.dr. Djanggan,SpPD, SpJP

Summary of Data Base

Female/56 yo/W.26 Chief Complaint: Chest pain (autoanamnesa and heteroanamnesa with her daughter) Patient suffered from chest pain since afternoon after had hemodialisa. Chest pain referred to her back but it didnt referred to her arm. The chest pain followed by cold sweating. And her symptoms appeared when she was resting. This is the first experience for her for having chest pain. And followed by shortness of breath. But, it was absent before. Patient had her first HD on November 2013, twice a week at RSSA.

History of past illness: CKD since November 2013 on HD twice a week. HT history known since patient was diagnosed with CKD at RSSA DM since approx. 9 years old ago, and poorly controlled. History of family: No family that have same complaint with her History of medication: History of privation and social: She was unjob, married already, the last education was high school

Physical examination
BP =120/80 mmHg PR = 84 bpm, regular,strong RR = 20 tpm GCS 456 Icteric (-) JVP R+3 cm H20 Tax : 36,5 General appearance look moderately ill Head/neck Thorax cor Anemic (+)

Ictus visible Palpable at Ictus ICS V MCL S, RHM ~ SL D, LHM ~ Ictus S1 S2 single, mur mur -

lung

Simetric, SF D = S

vv vv vv

Rh - -++

Wh - ---

Abdomen

Flat,soefl, BS(+)N, liver span 8 cm, traubes space tympani(+), shifting dullness (-)
warm acral (+) Edema -/+/+

Extermities

LLab
Leucocyte

LABORATORY FINDING
Result Normal Value 3.500 10.000

4130

/l

Basofil
Eosinofil Neutrofil

0,2
2.9 90.4 5.8 0.5 7.70 80.90 25,80 24.20 191000 90 170.20 6.78 11,73

0-1
0-4 51-67 25-33 2-5 11.4-15.1 80-93 27-31 38-42 142000-424000 <200 20-40 <1,2

%
% % % g/dl Fl Pg % Mm3 mg/dl mg/dL mg/dL

Limfosit
Monosit Hemoglobin MCV

MCH
PCV Trombocyte RBS

Ureum
Creatinin BUN/Creatinin Ratio

Lab SGOT SGPT Na K Cl Cpk Ckmb Trop I 15 12 140 5.04 117 68 20 0,5

Result U/L U/L

mmol / L mmol / L 0 32 0 33

Normal Value

136 145 3.5 5.0

mmol / L

98 106

26-192 7-25
<1

Blood Gas Analysis (10 lpm NRBM)

PH : 7.32 (N: 7.35-7.45) PCO2 : 30.2 mmHg (N: 35-45) PO2 : 103.7 mmHg (N: 80-100) HCO3 : 15.8mmol/L (N: 21-28) O2 Sat Arterial: 95.5 % (N > 95) BE : -10.5mmol/L Conclusion : Acidosis metabolic partially compensation ( severe hypoxemia)

ECG

ECG Dec 05th 2012

Sinus Rhythm, heart rate 98 bpm Frontal Axis : normal Horizontal Axis : normal PR interval : 0,12 QRS complex : 0,08 QT interval : 0.40 ST depresi II, III, avF

Conclusion : Sinus rhythm with rate 98 bpm. ST depresi inferior

CXR

CXR (february 19th 2014)

AP position, asymetris , enough KV, less inspiration Soft tissue normal, bone normal Trachea in the middle Hemidiaphragm D domeshape and S close radioopaque shadow Phrenico costalis angle D and S sharp Pulmo D/S : medial and lower pulmo bronchovesicular pattern increase Cor: site normal, cardiac waist dissappear, CTR ratio was 50% Conclusion : congestive pulmonum

CUE AND CLUE Female / 56 yo/W26 AX : Typical chest pain History of DM type II History of HT LF: Cpk 68 Ckmb 20 Trop I 0,5

PL 1. NSTEAC

IDx

PDx Cardiac enzime serial Corone aterography

PTx bed rest 02 4-6 lpm NC Total fluid 1500 cc/day Balance fluid -500cc/24 hours UFH bolus 60 mg/kgBW Contious maintenance 12mg/kgBW/ day Inj furosemide 20mg-0-0 Po : ASA 1x80 mg CPG 1x 75 Simvastatin 0-0-20mg Captopril 3x25 mg ISDN 3x10 mg

PMo

Ecg ST depresi II, III, avF

Female/56 yo/w26 Ax: History DM type II

DM Type II poorly control e

GD1, GD2, lipid profile

Wait result

Subjectiv VS

CUE AND CLUE

Female/ 56 yo/ W26 Ax : Diagnose as kidney failure History of DM Type II History of HT Last HD 18-2-14 PE : BW : 60 kg Pale conjunctiva Inserted double lumen at right supraclavicula Rhonki basal at both lung Edema at lower extremitis Lab : Hb 7.70 mg/dl Ureum 170.20 Creatinine 6.78 eGFR 6.7 ml/min/1.73m2 BGA acidosis metabolic
Female/56 yo/w26 PE: Pale conjunngtiva Lab : HB 7.70 mg/dl MCV :80.90 MCH 25.80

PL
3. CKD stage V on HD twice a week

IDx
7.1 Diabetic kidney disease 7.2 GNC

PDx
USG abdomen

PTx
soft diet 1700 kcal/day Low salt <2g/day Protein 60 gram/day Negative fluid balance 500cc Cito hemodialized

PMo
subjective TTV Urine production

4. Anemia Normocrom microcytair

4.1 anemia on chronic kidney disease 4.1.1 deficiency fe 4.1.2 chronic blood loss

Blood smear SI TIBC Ferritin

Tranfusi PRC 1 klof/ day until Hb 8mg/dl Durante HD Waiting for SI TIBC Ferritin result, paln to give epo if iron profile was normal

Iron profile Subjective Vital sign

Condition this morning

GCS 456 BP140/95 mmHg HR 102 bpm RR 20 tpm UOP 20cc/ 3 hour

Thank You!