MORNING REPORT

Tuesday, 15th March 2011

PHYSICIAN INCHARGE:
IA : dr. Budi dr. Angela
IB : dr. Nurike, dr. Serina
II : dr. Fajar
III : Prof DR dr Handono K., SpPD KR
MODERATOR: Prof DR dr. Achmad Rudijanto , Sp.PD-K

Summary of Data Base

Male/ 56 y.o/ W 22
Chief Complain : shortness of breath
Shortness of breath since 3 weeks before admission,
gradually onset, and getting worse each day. Shortness
of breath relieved when patient rest and sit down, but
getting worse when patient sleep with 1 pillow, so he
sleep with more than 3 pillow. In the last 10 days patient
complain that he cough, productive cough, with whitish
sputum. But in the last 5 days, he saw that his sputum
was pink.

He also complain about leg swelling for 5 days and

getting bigger. Patient has been diagnose with kidney
disease for 5 days ago in Mardi Waluyo hospital

History of hypertension 4 years, never control.

History of epylepsy for 4 years, with drug carbamazepime
No history of diabetes

Physical examination
BP = 130/90mmHg

PR = 85 bpm

RR = 22 tpm

General appearance looked moderately ill

GCS 456

Head

Anemic +

Icteric -

Neck

JVP R + 3 cm; 30

Thorax:

Cor:

Lung:

Tax : 37 C

Invisible and palpable ICS VI MCL Sinistra

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

Rh - - Wh - + +
++
+ +
++

Abdomen

Soeppel, Liver span 10 cm, troube space tympani

Extremities

Warm, edema foot +/+

Laboratory finding
Lab

Value

Lab

Value

Leukocyte

6.800

3.50010.000/L

Natrium

126

136-145 mmol / L

Haemoglobine
MCV

7,8
77

11,0-16,5 g/dl
80-97

Kalium

5,16

3,5-5,0 mmol / L

MCH

26,4

26,5-33,5

Chlorida

92

98-106 mmol / L

PCV

22,7

35-50%

RBS

107

Trombocyte

220.000

150.000390.000/L

SGOT

64

11-41U/L

Ureum

266,7

10-50 mg/dL

SGPT

41

10-41U/L

Creatinine

17,29

0,7-1,5 mg/dL

Albumin

2,90

3,5-5,5 g/dL

eGFR

6,55

Urinalysis
SG:1,015

pH: 5

Protein: 4+ Glucose: -

Ery: 4-5 /hpf

Leu: 0-2 /hpf Bacteria: +

Nitrite: -

Keton: -

Ery: 4+

Laboratory Finding
BGA

Value
(Suplemental O2 2 Lpm)

PH

7,302

7,35-7,45

PCO2

20,0 mmHg

35-45

PO2

138,1 mmHg

80-100

HCO3

13,9 mmol/ l

21-28

O2 saturation

98,6 %

> 95%

Base Excess

-16,7

-3 until +3

Conclussion

Metabolic acidosis

ECG (14/3/2011)
Sinus rhythm, Heart rate 86 bpm
Frontal Axis
: normal
Horizontal Axis : Clockwise rotation
PR interval
:0,12
QRS complex : 0,08
QT interval
:0.36

Conclusion : sinus rhytm with frequency 86 bpm

CXR (14/3/2011)
AP position, asymetric
Trachea in the middle
Soft tissue and bone normal
Right and left phrenico-costalis angle are sharp
Right and left hemidiaphragm are dome shape
Lung: infiltrate in medial and basal area of the lung
Cor site and shape are normal, CTR: >50%

Conclusion: lung oedema and cardiomegaly

CUE AND CLUE

Male/44 yo
Orthopneu
Paroxysmal
nocturnal dyspneu
Hemoptoe
Hypertension since
4 year ago (200/)
Unroutinely control
BP:130/90
PR:85
RR:22
Anemic
Cardiomegaly
Rales +/+
Edema ekstremity
Hb:7,8
MCV:77
MCH:26,4
Ur:266,7
Cr:17,29
eGFR:6,55
K:5,16
Albumin:2,90
UA:
CXR:infiltrate in
medial and basal
area of the lung

PL

IDx

1.
Shortne
ss of
breath

1.1.Uremic
lung
1.2.Heart
Failure stage C
fc IV

PDx

PTx

PMo

O2 2-4 Lpm via NC

Venflon
High calory, 1900 kcal/day,
protein (30g/day), low salt (12g/day)
Fluid restriction
Drip Furosemide 10mg/hour
HD cito

Subje
ctive
BP
HR
RR
Urine
produ
ction
Body
weigh
t

CUE AND CLUE

Male/44 yo
Shotness of breath
Hypertension since
4 year ago (200/)
unctrolled
BP:130/90
PR:85
RR:22
Anemic
Cardiomegaly
Rales +/+
Edema ekstremity
Hb:7,8
MCV:77
MCH:26,4
Ur:266,7
Cr:17,29
eGFR:6,55
K:5,16
Albumin:2,90
UA:

PL

Idx

PDx

PTx

Pmo

2.Chroni
c
Kidney
Disease
stage 5

2.1.Hypertensi
ve
nephrosclerosi
s
2.2.GNC
2.3.PNC

USG
Abdome
n
Doppler
Urine
Esbach

Same as above:
O2 2-4 Lpm via NC
High calory, 1900 kcal/day,
protein (30g/day), low salt (12g/day)
Fluid restriction
Drip Furosemide 10mg/hour
HD elective

Subje
ctive
BP
HR
RR
Urine
produ
ction
Body
weigh
t

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

Male/44 yo
Orthopneu
Paroxysmal
nocturnal dyspneu
Hypertension
since 4 year ago
(200/)

3.Heart
Failure
stage C
fc IV

3.1.HHD
3.2.CAD
3.3.Uremic
cardiomyop
athy

Echoca
rdiogra
phy

O2 2-4 Lpm via NC

Drip Furosemide
10mg/hour

Subje
ctive
BP
HR

Male/44 yo
BP:130/90

4.Hypert 4.1
ension
Secondary
stage I
4.2 Primary

USG
Abd
Dopple
r

Drip furosemide
10mg/hour

Subje
ctive
BP

Male/44 yo
Hb:7,3
MCV:77
MCH:26,4

5.Anemi
a
hypochr
omic
micocyt
er

SI/TIBC
Ferritin
serum

Plan to give erythropietin

Hb

BP:130/90
Cardiomegaly
Rales +/+

5.1.Due to
No.2
5.2.Low
intake

CUE AND CLUE

PL

Idx

Male/44 yo
K:5,16

6.Mild
hyperkal
emia

6.1.due to
No.2

Male/44 yo
pH:7,302
pCO2 :20,0
HCO3:13,9
BE:-16,7

8.Metabo 8.1.due to
lic
No.2
acidosis

Male/44 yo

PDx

PTx

PMo

Drip furosemide 10
mg/hour

Rech
eck
kaliu
m

NaBic 75 mEq (iv bolus)

NaBic 75 mEq drip in 100
ml D5%

Rech
eck
BGA

Thank you