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Morning Report

th

Friday, September, 7 2012

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

Chief Complaint: nausea and vomiting
Patient presented with the chief complaint nausea and vomiting since 3 days ago, frequency 10x/day, volume ½ glass,
contained of water and residual food. Passing stool and urine was normal. Patient may flatus normally.
He also complained of decrease of appetite since 3 days ago, about 3 spoon/meal, 3x/day. He didnt took his medicine in the
past 3 days because he felt them at his house in Kasembon.
He was also presented with leg swelling since 5 months ago, started in eyelid, then on his legs, subsided with medications.
History of past illness: He had Hypertension since 1 year ago, unroutinely controlled. He also had right stone removal
surgery 1 year ago. He used to be hospitalized on May 2012, diagnosed as kidney disease and undergo routine hemodialysis
on Tuesday and Saturday. DM is denied.
Family History: No one in family that had kidney disease.
Social History: No history of drink traditional medicine.

Physical Examination
0

BP= 188/111 mmHg
PR= 89 bpm regular
RR =18 tpm
Ax. Temp.= 36.5 C
General App.: looked moderately ill, attached to O2
GCS : 456
NRBM 4 lpm
Looked normoweight
Head
Anemic conjunctiva (+)
Icteric sclerae (-)
Lnn. Enlargement (-)
0
Neck
JVP : R + 3 cm H2O; 30
Thorax
Cor
Ictus invisible, palpable at 1 cm lateral sixth ICS, MCL S
RHM ≈ S line D
LHM ≈ ictus
S1, S2 single, no murmur
Pulmo
Symmetric; SF D=S; S| S V | V Rh -| - Wh - | S| S V | V
-|-| S| S V |V
-|-|Abdomen
Extremities

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/µL

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 µm3
26.5-33.5 µm3

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/µl
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

2

2

Eos/Ba/Neu/Ly/Mo

URINALYSIS -> not yet performed
CXR :
AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue normal, Phrenicocostalis
angle D/S sharp, Hemidiaphragm D/S domeshape, Pulmo: increased of broncho vascular shadowing, Cor: site normal, size
CTR about 60%,and shape normal.
Conclusion : Cardiomegaly

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

4.1 due to Epo
defficency
4.2 due to chronic
disease

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

Balance fluid negative
Venflon
Renal diet: 1900Kcal/d; Low
salt<2gr/d; protein 1-1.2
gr/KgBW/day, low potassium
Furosemid 40-0-0 mg
HD elective

S
VS
UOP

Ca gluconas 1000 mg
Rapid acting insulin 10 iu
D40% 50 cc

SE, RBG post
correction
ECG

Ferritin serum,
blood smear,
reticulocyte
count

Folic Acid 1x3 tab
B6/B12 3x1 tab

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