POMR 4 – Nephrology

Obstructive Nepropathy in 51 y.o

Patient with Bladder Tumor
Supervisor : Dr. dr. Hani Susianti Sp.PK (K)
Presenter : Hambiah Hari Oki
Base Data
51 y.o male patient admitted to RSSA ER on 16th July 2020
Chief Complaint : Bloody urine since 1 year
• Patient admitted to RSSA ER with bloody urine since a year ago and
worsened since 2 days ago
• He was also experiencing difficulty to urinate that worsened with
blood clot from bloody urine
• Patient had diminished appetite since 6 months ago. Nausea and
vomit occurs often
• Fever is denied
Base Data
History of Past illness
Medical History
• Diagnosed with bladder tumor since a year ago, doesn’t get any
definitive treatment
• There is no history of diabetes mellitus and hypertension
 Physical Examination
General status Moderately ill, GCS : 4-5-6
Weight : 55 kg , Height : 170 cm, BMI : 19.03 kg /m2
Vital sign BP : 125 / 85 mmhg HR : 87 tpm, RR : 30 tpm T : 36.5°C
SpO2 : 98 % RA
Head & Neck Light reflex +/+ , Anemic conjunctiva -/-, Icteric sclera -/- Lymph
node enlargement –
Thorax P : symmetrical, VBS +/+, Rh + / + , Wh -/-
C : Cardiomegaly -, Regular S1/S2, murmur -, gallop -
Abdomen Convex , bowel sound (n), Shifting dullness -, Suprapubic
tenderness
Extremities Warm + /+ , edema - / -
Skin Within normal limit
Genitalia Within normal limit
Laboratory
Hematology 16/07 Reference
Hb 5.6 11.4 – 15.1 g/dL
RBC 2.07 4.0 – 5.0 x 106/µL
Ht 15.2 38 – 42 %
MCV 73.4 80 – 93 fL
MCH 27.1 27 – 31 pg
MCHC 36.8 32 – 36 g/dL
RDW 15.4 11.5 – 14.5 %
WBC 17.5 4.7 – 11.3 x103 /µL
Diff count -/-/-/92/3/5 0-4/0-1/-/51-67/25-33/2-5

PLT 412 142 – 424 x 103/µL

Clinical Chemistry 16/07 Reference
RBG 106 <200 mg/dL eGFR
CKD EPI:
Ureum 123.6 16.6 – 48.5 mg/dL 4.98
Creatinine 10.62 < 1.2 mg/dL mL/min
/1.73m2
Albumin 2.44 3.5 – 5.5 mg / dl

16/07 Reference
PPT 10.3 9.4 – 11.3
Control 10.5
APTT 31.4 24.6 – 30.6
Control 26.3
 Electrolyte Results Reference

Na 110 136 – 145 mmol/L

K 3.78 3.5 – 5.0 mmol/L

Cl 79 98 – 106 mmol/L

Serum osmolality : 246 mOsm/kg

16 / 07 Reference
CRP 3.48 < 0.3
Procalcitonin 0.32 < 0.5 ng/ml
 BGA 16/05 Reference
(22.00)
pH 7.39 7.35 – 7.45
pCO2 28.7 35 - 45
pO2 34.4 80-100
HCO3 17.4 21-28
BE -7.8 (-3)-(+3)
SatO2 66.8 >95 %
Hb 5.6
Suhu 37

Vein sample
 PCCL PL IDx PDx
1. 51 y.o patient Hematuria • Hematuria dt • Abdominal Xray
Laboratory examination bladder tumor
• Hemoglobin 5.6 g/dl Dd/ urinary tract Monitoring
• Hematocrit 15.2 % stone • Urinalysis

Anamnesis and
Physical examination
• Bloody urine since a year ago
• Prior diagnosed with bladder
tumor a year ago
• Suprapubic tenderness
 PCCL PL IDx PDx
2. 51 y.o patient Renal • AKI dd / Acute • Renal USG
Laboratory examination Insuficiency on CKD dt
• ↑ Ureum 123.6 mg/dl obstructive Monitoring
• ↑ Creatinine 10.62 mg/dl nepropathy dt • Ureum, creatinine
Anamnesis and bladder tumor • Urine output
Physical examination
• Prior diagnosed with bladder
tumor a year ago
• Suprapubic tenderness
 PCCL PL IDx PDx
3. 51 y.o patient Anemia • Anemia d.t • Peripheral Blood
Laboratory examination chronic disease Smear
• ↓ Hemoglobin 5.6 g/dl & chronic blood • SI, TIBC
• ↓ Hematocrit 15.2 % loss dd / iron • Reticulocyte
• ↓ MCV 73.4 fl deficiency Monitoring
• CBC
Anamnesis,
Physical examination and other
• Hematuria
• Prior diagnosed with bladder
tumor a year ago
 PCCL PL IDx PDx
4. 51 y.o patient Electrolyte • Hyponatremia • Urine electrolyte
Laboratory examination Imbalance hipoosmolal • Urine osmolality
• ↓ Natrium serum 110 mmol/l euvolemic Monitoring
• ↓ Chloride serum 78 mmol/l • Hypochloremia • Serum electrolyte
• ↓ Serum osmolality : 246 dt excessive loss
mOsm/kg

Anamnesis,
Physical examination and other
• Nausea and vomiting occurs
often
 PCCL PL IDx PDx
5. 51 y.o patient Susp. Sepsis • Susp. Sepsis • Peripheral blood
Laboratory examination dt lung smear
• ↑ Leukocyte (17.50 x 103 / μL) infection dd/ • Chest Xray
• Neutrophilia UTI • Serum lactate
• ↑ CRP (3.48) • Bilirubin total,
direct, indirect
• Blood culture
Anamnesis, • Procalcitonin (after
Physical examination and other 6 – 12 hrs)
• Prior diagnosed with bladder tumor
a year ago Monitoring
• Rhonkii on both side of the lungs • CBC
• SOFA score 4 • Ureum, creatinine
• Urinalysis
 PCCL PL IDx PDx
6. 51 y.o patient Hypoalbumine Hypoalbuminemi • AST / ALT
Laboratory examination mia a dt susp. renal • ALP
• ↓ Albumin (2.44 g/dl) disease dd / • Gamma GT
• liver • Abdominal USG
insufficiency • Total protein
Anamnesis, • low intake • Bilirubin total,
Physical examination and other direct, indirect
• Prior diagnosed with bladder tumor
a year ago Monitoring
• Nausea and vomiting occurs often • Albumin
Thank You for Your Kind Attention