Morning Report

th
Monday, September 24 2018
PHYSICIAN IN CHARGE (22/9/18):
IA: dr. Aditya Noor Rachman
Chief: dr. Yuni, dr. Fadhila
Facilitator: dr. Nurul Aina, Sp.PD, FINASIM
Summary of Database
Identity : Mrs. G / 46 yo
Chief complaint : Fatigue
Autoanamnesis
Present Medical History
• Patient complaint fatigue and shortness of breath since 8 hours priors to admission.
She felt tightening in the chest since around 3 days ago. It was neither precipitated by
activity nor relieved with rest and position. It was not accompanied with pink frothy
sputum. She felt dizziness. The moment complaint occurs, she was taking a routine
hemodialysis for 5 hours. After that, the complaint getting worse.
• She was getting paler, more fatigue, and easy to get breathlessness since 1 years ago.
• She complaint swollen at lower extremities since 2 days ago. There are no pain,
redness or history of trauma. It was relieved by lifting her feet.
• She also complaint about decreased of appetite since 1 weeks ago, she only ate 2-3
spoons a day accompanied with slight nausea but no vomiting.
• She was diagnosed with chronic kidney disease since 1 years ago, and she got
hemodialysis twice a week (Wednesday, Saturday) at Ulin Hospital. She always taking
her medicine (folic acid, CaCO3, anti hypertension) from HD unit routinely.
Past Medical History
Hypertension (+) since 1 years ago when she was diagnosed with CKD, DM (-)
Family Medical History
Hypertension (+), DM (+), CKD (-)
Medication History:
Amlodipin, Candesartan, Furosemid since 1 years ago
Allergic History:
Shrimp
Operation History:
AV shunt in October 2017 at left arm
Social History
She lives with her husband. She didn’t work.
 Physical Examination
General appearance : looked mildly ill Looked height : 148 cm
GCS : 456 Weight : 45 kg
VAS Score : 2/10 BMI : normoweight 20.5
BP : 120 / 60 mmHg PR : 84 bpm, reguler, strong, SpO2 : 99 % RR : 24 tpm Tax : 36.7 oC
Head Conjunctival pallor (+/+), scleral icterus (-), cyanosis (-)
Neck JVP R + 2 cm H2O, 30o position
Ictus invisible & palpable at ICS V MCL S
LHM = ictus
Heart
RHM = SL D
S1, S2 single, murmur (-), gallop (-)
Inspection: symmetric
Chest
Palpation Percussion Auscultation Rhonchi Wheezing
Lung n n s s v v - - - -
n n s s v v - - - -
n n s s v v - - - -
Inspection: flat
Auscultation: normal bowel sound
Abdomen
Percussion: tympanic, hepatomegaly (-), splenomegaly (-), shifting dullness (-)
Palpation: epigastric tenderness (+), fluid wave (-)
Extremities leg edema (+), warm acral (+), pale (+), AV shunt at left arm
 Laboratory Findings (22/9/18 – 13.00)
Lab Result Value Lab Result Value
Hemoglobin 7.6 14.0 – 18.0 Ureum 29 0 – 50
Leukocyte 6.5 4.0 – 10.5 Creatinine 2.56 0.57 – 1.11
Erythrocyte 2.94 4.10 – 6.0 Natrium 134 136 – 145
Hematocrit 23.5 42.0 – 52.0 Kalium 3.1 3.5 – 5.1
Platelet 260 150 – 450 Chloride 101 98 – 107
MCV 79.9 75.0 – 96.0 Sosm 279 280 – 285
MCH 25.9 28.0 – 32.0
Granulocytes 81.4 50.0 – 81.0
Lymphocytes 9.4 20.0 – 40.0
RBG 122 < 200
SGOT 21 5 – 34
SGPT 11 0 – 55
 CUE AND CLUE PL IDx PDx PTx PMo
Female / 46 yo 1. CKD stage V 1.1 Hypertensive USG O2 3 lpm Subjective
Ax: on routine nephrosclerosis Urinalysis Renal diet < 1700 kcal / day Vital sign
- Shortness of breath hemodialysis 1.2. GNC Low salt diet < 2 g / day Ur, Cr, electrolyte,
- Fatigue Protein diet 1 - 1.2 g / kgbw / RBG post HD
- Pale day
- Decreased of appetite Inj. Furosemide 3 x 40 mg PEd:
- Swollen feet PRC transfusion until Hb > 8 Explained recent
- Diagnosed as CKD on g/dL condition,
routine hemodialysis HD as schedule management, and
- History of HT prognosis

PE:
- BP 140/80 → 120/60
- RR 28 → 24
- Conjunctival pallor
- Leg edema
- Pale extremities

Lab:
- Hb 6.9 → 7.6
- Ureum 29
- Creatinine 2.56
- Natrium 134
- Kalium 3.1
 CUE AND CLUE PL IDx PDx PTx PMo
Female / 46 yo 2. Renal anemia 2.1. EPO deficiency Blood smear Plan to give EPO as indicated Subjective
Ax: 2.2. Decreased of red Vital sign
- Shortness of breath blood cell life span PRC transfusion or durante Hb level
- Fatigue HD transfusion until Hb > 8 Electrolyte
- Pale
PEd:
PE: Explained recent
- Conjunctival pallor condition,
- Pale extremities management, and
prognosis
Lab:
- Hb 7.6
- MCV 79.9
- MCH 25.9
 CUE AND CLUE PL IDx PDx PTx PMo
Female / 46 yo 3. Hypertension 3.1. Secondary USG doppler Low salt diet < 2g / day Subjective
Ax: on treatment Hypertension PO. Amlodipin 1 x 10 mg Vital sign
- Dizziness 3.1.1. PO. Candesartan 1 x 16 mg
- History of HT Renoparenchymal PEd:
hypertension Avoid salty food
PE: 3.1.2 Renovascular
- BP 140/80 → 120/60 hypertension
- RR 28 → 24
- Conjunctival pallor 3.2. Primary
- Leg edema
- Pale extremities

Lab:
- RBG 122
- Na 131
- Sosm 279
 CUE AND CLUE PL IDx PDx PTx PMo
Female / 46 yo 4. Mild 4.1. dt No. 1 No immediate correction Subjective
Ax: hyponatremia needed if mild hyponatremia Vital sign
- Shortness of breath hypoosmolar Treat underlying causes
- Fatigue hypervolemic Fluid restriction Serum electrolyte
- Pale
- Decreased of appetite
- Swollen feet
- Diagnosed as CKD

PE:
- BP 140/80 → 120/60
- RR 28 → 24
- Conjunctival pallor
- Leg edema
- Pale extremities

Lab:
- Hb 7.6
- Ureum 29
- Creatinine 2.56
- Natrium 134
- Kalium 3.1
 CUE AND CLUE PL IDx PDx PTx PMo
Female / 46 yo 5. Mild 5.1. Renal loss Treat underlying causes Subjective
Ax: hypokalemia 5.2. GI loss Vital sign
- Shortness of breath 5.2. Inadequate intake
- Fatigue Serum electrolyte
- Pale
- Decreased of appetite
- Swollen feet
- Diagnosed as CKD

PE:
- BP 140/80 → 120/60
- RR 28 → 24
- Conjunctival pallor
- Leg edema
- Pale extremities

Lab:
- Hb 7.6
- Ureum 29
- Creatinine 2.56
- Natrium 134
- Kalium 3.1
 Problem Analysis

Hypertension

HT
nephrosclerosis

Mild hyponatremia
Fluid
hypoosmolar overload ESRD Diuretic Hypokalemia
hypervolemic

EPO def.

Anemia
 Risk Factor
Problem Theory Factual

• Glomerulonephritis
• Diabetes Melitus
CKD stage V • Obstruction and infection Hypertension
• Hypertension
• Other Causes
 Risk Factor
Problem Theory Factual
Increased Red Blood Cells Loss or
Destruction
• Acute Blood loss
• Hypersplenism
• Hemolytic Disorders
Decreased red blood cell production
• Primary Causes: Marrow Hypoplasia,
Anemia Myelopathies Chronic Kidney Disease
• Secondary Causes: Chronic Kidney
Disease, Liver disease, Endocrine
deficiency states, Anemia of chronic
disease, sideroblastic anemia
Overexpansion of Plasma Volume
• Pregnancy
• Overhydration
 Risk Factor
Problem Theory Factual

• Increased age
• Race black
• Family history
• Overweight/Obese
• Not physically active
Hypertension Family history
• Using tobacco
• Sodium diet
• Little potassium diet
• Little vitamin D
• Alcohol
 Management Analysis
Problem Theory Factual

Stages of CKD
GFR
Stage mL/min/1.73
m2
Goals CKD st V → renal replacement
Diagnosis of underlying
therapy
1 >90 condition & comorbidities, slow
progression, CV risk reduction
Renal diet < 1700 kcal / day
CKD stage V 2 60 – 89 Estimate progression
Low salt diet < 2 g / day
3 30 – 59 Evaluate and treat complications
Prepare of renal replacement
Protein diet 1 – 1.2 g / kgbw / day
4 15 – 29
therapy Inj. Furosemide 3 x 40 mg
5 < 15 Dialysis or renal replacement HD as schedule
 Management Analysis
Problem Theory Factual

Renin–angiotensin aldosterone system blockers

Diuretics
Calcium-channel blockers
Centrally acting alpha-adrenergic agonists
Alpha-blockers Low salt diet
Direct vasodilators
Hypertension Low salt intake PO. Amlodipin 1 x 10 mg
We recommend achieving or maintaining a PO. Candesartan 1 x 16 mg
healthy weight (BMI 20 to 25)
Limiting alcohol intake to no more than two
standard drinks per day for men and no more
than one standard drink per day for women)
Condition This Morning
• GCS : 456
• BP : 120/70
• HR : 82
• RR : 20
• Tax : 36.7
Thank You