CUE AND CLUE

Female/36yo
Ax
SOB with frothy
sputum
history of HT
since 1 year ago
PE:
BP:
240/100160/1
00
PR :123
90bpm
RR: 40x24x
Rochi in all area
of the lung (ER)
Cardiomegaly
Lab:
Ur/Cr:
120.1/10.8
Proteinuria
Ro Thorax:

PL

IDx

1. ALO

1. Non
cardiogenic
1.1 Uremic
Lung
2.Cardiogeni
c
2.1 HF st C
fc IV

PDx

BNP

PTx

O2 8-10 lpm NRBM

Semi-fowler position
Inj. Furosemid 40 mg
than drip Furosemide
continuous iv 10 mg/hr
(ER)
Cito HD

PMo
BP
HR
RR
Urine
producti
on
sign of
overload
syndrom
e

CUE AND CLUE

Female/36yo
SOB
Nausea and vomitting
History of HT
Dry skin
PE:
BP: 240/100150/100
PR :123 90bpm
RR: 40x24x
Rochi in in basal

area lung D
and S
Leg edema
Lab:
Hb : 6,0
Ur/Cr:120.1/10.8
eGFR : 5.24
mL/min/1.73m2
BGA: metabolic
acidosis
UL: Protein +3
Erytrocite +3
Urine production
hours 100c/8 hour
CXR : lung edema

PL

IDx

PDx

PTx

2.
2.1 GNC
Acute
2.2 PNC
on
CKD st
V

Abdo
minal
USG

Diet :
Cito HD
Renal diet 1700ccal/day,
low salt diet < 2 g/day,
protein 0,8-1 mg /kg
BW/day
Inj. Metoclopramide 3x10
mg prn

PMo
Subj
VS
Ur/Cr
SE
Urine
prod

CUE AND CLUE

PL

IDx

PDx

PTx

Female/36yo
History of
hypertension since 1
year ago

3. HT
emerg
ency

3.1
Renopharen
chimal HT
3.2 Primary
HT

Fundus
copy

Furosemide 10mg/ hr
continuous iv (ER)stop
than Po:
Captopril 2x25 mg (ward)

PE:
BP:
240/100150/100
PR :123 90bpm
RR: 40x24x
Rhonki in all area of
lung (ER)
Ronchi in in basal
area lung D and S
(ward)
CXR : cardiomegaly
and lung edema

PMo
BP
Subj

CUE AND CLUE

Female/36yo
SOB

Orthopneu, PND,
DOE,
HT known since 1
year ago, unroutinely
controlled
PE:
BP:240/100150/100
PR :123 90bpm
RR: 40x24x
JVP R+ 4 cmH2O
(45)
Ictus visible, palpable
at ICS V 2cm lateral
MCL S
Hemic murmur
Rochi in in basal area
lung D and S
Lab:
Urine production
c/hour
CXR : cardiomegaly
and lung edema

PL

4. HF st C
fc IV

IDx

PDx

PTx

4.1 AHD
echocard O2 8 lpm NRBM
4.2 uremic igraphy
Semifowler position
cardiomyop
Furosemide 40-0-0
athy
mg
Captopril 2x25 mg

PMo
Subje
ctive
BP
Urine
produ
ction

CUE AND CLUE

Female/36yo
SOB
Cough 3 days before
admision
PE:
Ronchi in in basal
area lung D and S
Lab:
WBC : 15.710
Neu : 94,4 %

PL

IDx

5.
Coug
h+leu
cocyt
osis

5.1.
Pnemonia
CAP
5.2. reactive

PDx

PTx

Kultur
Inj Ceftriaxone 2x1 gr iv
and
(skin test)
gram
sputum
+
sensitivi
ty test

PMo
Sbj,V
S

CUE AND CLUE

PL

Female/36yo
Nausea, vomiting
Lab:
Na 114134
RBS 156
Ur 120,10
Cr 10,08
eGFR 5.24
ml/min/1.73 m2
Osmolality 256 mOsm

6.
Hyponatr
emia
hypoosm
olar
hypervole
mic

IDx

Dt CKD stV

PDx

PTx

Furosemide as above

PMo
SE

CUE AND CLUE

Female/36yo
Lab:
Konjunctiva pale
Hb : 6.0
MCV : 71.5
MCH : 25.1

PL

7. Anemia
hypochro
mic
microcytic

IDx

7.1 Fe
defficiency
7.2 low
intake

PDx

PTx

Retic Confirm diagnosis

count
Blood
smear
SI
TIBC
Seru
m
Ferriti
n

PMo
CBC

CUE AND CLUE

Female/36yo
Easily bruising
PE : hematome at
upper arm
Lab:
Trombo : 86,000

PL

IDx

8.
8.1 uremic
Thromboc thrombocyto
ytopenia
pathy

PDx

PTx

Treat underlying
disease

PMo
CBC
Blee
ding
tend
enci
es

Problem analysis
Hypertension

HF st C Fc IV

ALO
Hyponatremia

CKD st V
Anemia
immunocompremise

Pnemonia

Metabolic acidosis

Thrombocytopenia

Risk Factor CKD

Diabetes
High blood pressure
Heart disease
Smoking
Obesity
High cholesterol
African-American, Native-American or Asian-American
race
Family history of kidney disease
Age 65 or older

Management Analisis
Emergency
O2 8-10 Lpm NRBM
HD cito
Drip Furosemide 10 mg/hour (ER)

Urgency
Kidney diet 1700 kcal/day
Low salt diet < 2gr/day
Po: Captopril 2x25 mg

Non Urgency
-

Condition this morning

GCS
: 456
BP
: 150/90 mmHg
PR
: 100 bpm
RR
: 20 tpm
Tax
: 36,9
Urine production : 100cc/h

Thank You
L/O/G/O

Management analysis
1.
2.
3.
4.

5.
6.
7.
8.

Hypertensive therapy use ACE/CCB

Diabetes : glycemic control (A)
Dyslipidemia : control lipid profile, measured serial total
cholesterol, HDL, LDL, TG (A)
Lifestyle management :
smoking cessation (B),
weight reduction (B),
protein dietary control (D),
alcohol intake (B),
exercise (D), dietary salt intake (B)
Anemia : use Erythropoetin (D), Iron suplement (D)
Mineral metabolism abnormalities : both Calcium, phosphate,
parathyroid hormonal check (D), treat if there was symptoms (D)
Proteinuria : should check the loss of protein and if treated use
ACE inhibitor (A)
Renal Replacement therapy (HD)