SUMMARY OF DATA BASE

Mr. M hasanudin , 35 yo, w 26 CHIEF COMPLAINT : shortness of breath HISTORY OF PRESENT ILLNESS : - Patient suffered from shortness of breath since 1 week ago, continuosly, worsened 2 days before admission. - Previously, he suffered from shortness of breath since 2 month ago, especially if she walked more than 10 meters, relieved by rest, but in the last week his condition didnt improve with rest. - Patient sleep using 3 pillows and sometimes wake up at night because of SOB

SUMMARY OF DATA BASE

He also complained cough one week ago, with yellowish sputum and worsened at two days ago. He also complained about low grade fever, 3 days ago, intermitenly, relieved by itself. General weakness since two month ago, gradually onset and accompanied by decrease of appetite.

SUMMARY OF DATA BASE

He has been diagnosed as hypertension since 5 years ago, about >150 mmHg and never controlled He has been diagnosed as kidney disease since 2 months ago and got HD routinely every week every friday The last medication : amlodipin 10 mg 1x Family history : his mother had HTN

PHYSICAL EXAMINATION
GENERAL APPEREANCE LOOKED MODERATELY ILL GCS : 456 BP : 170/90 mmHg (w) Looked normoweight PR : 100 bpm, reguler RR : 28 tpm, tacypneu T ax : 37.8 C

HEAD NECK
THORAX COR

ANEMIC (+) JVP R + 4 cm 45

ICTERIC (-)

Uremic frost

ICTUS : VISIBLE , PALPABLE AT ICS 5 1cm lat mcl S RHM : SL D LHM : ICTUS S1 S2 SINGLE MUR-MUR (-) SIMETRIS FS D=S Rhonchi in medial and basal area of lung Wh : - - -

LUNG

ABDOMEN
EXTREMITAS

FLAT Soufle BS + (N) LIVER SPAN 10 cm TRAUBES SPACE tymphani

EDEMA -/WARM

LABORATORY FINDINGS
LAB
Leucocyte

VALUE
18.170 3.500-10.000/L 11,0-16,5 g/dl

LAB
Natrium Kalium

VALUE
140 6.17 136-145 mmol / L 3,5-5,0 mmol / L

Haemoglobin 7.30

PCV
Trombocyte MCV

22,2%
294.000 85,7

35-50%
150.000-390.000/L 80-97

Chlorida

106

98-106 mmol / L

SGOT

30

11-41 U/L

MCH

28.2

26,5 - 33,5

SGPT
Albumin

41
3,5

10-41 U/L
3,5 5,5 g/dl

RBS Ureum Creatinin Gfr

104 191 26,43 3,86 10-50 mg/dL 0,7-1,5 mg/dL

BLOOD GAS ANALYSA

Lab BGA PH PCO2 PO2 HCO3 O2 saturation Base Excess Conclussion True O2 O2 10 lpm nrbm 7.57 23 80,3 21 97,1 -1,3 Alkalosis respiratorik 16%, severe hypoxemia Fio2 needed 0,38 equivalent with 4 lpm nrbm 7,35-7,45 35-45 80-100 21-28 >95 -3 until +3 Value

ecg

ECG
ECG :
Sinus tachycardia 124 bpm Frontal Axis

Horisontal Axis
PR interval QRS complex QT interval

: normal axis : normal axis : 0.12 :0.08' :0.40

- Tall T V3 V4
Conclusion : Sinus tachycardi 124 bpm tall T

cxr

CXR

AP position, KV less enough, asymmetric, Less inspiration Trachea in the middle, Bone N and soft tissue N, Phrenico costalis angle: D/S sharp Hemidiaphragma D/S covered by radioopaque Pulmo : patchy infiltrart, cephalitation at both area of lung Cor: looked cardiomegaly Conclusion : lung edema, cardiomegaly

CUE AND CLUE Male, 35 yo SOB DOE PND BP ; 170/90 RR 28 tpm PR : 100 bpm Tax : 37,8 Pale conjungtiva Rh (+) in medial and basal area Lab : Hb : 7.3 Leucocyte : 18.170 Ureum : 191 Creatinin : 26,43 Gfr : 3,86 Cxr : Lung edema, cardiomegaly

P List

INITIAL DIAGNOSE

PDx

PLANNING THERAPY

PMo

NT pro 1. ALO 1.1. non BNP cardiogenic 1.1.1. Uremic lung 1.1.2.pneumoni a CAP 1.2 cardiogenic 1.2. 1.HF st c FC IV

O2 8 lpm nrbm Semifowler position Fluid Balance Kidney diet 1900.k cal/day Low salt 2 gr/day Ptotein Diet 50 gr/day Drip furosemide 10 mg / hr Cyto HD

VS Subjec tive Ur/Cr Rh

CUE AND CLUE Male, 35 yo SOB Ckd on routinely hd Hypertension since 5 years BP ; 170/90 RR 28 tpm PR : 100 bpm Uremic frost Pale conjungtiva Rh (+) Lab : Hb : 7.3 Leucocyte : 18.170 Ureum : 191 Creatinin : 26,43 Gfr : 3,86 Cxr : Lung edema

P List

INITIAL DIAGNOSE

PDx

PLANNING THERAPY

PMo

2. CKD 1.1 st 5 on Hypertension HD nephrosclerotic 1.2. GNC

Kidney diet 1900 k cal Protein diet 1 gr/bw/day HD cyto Inj furosemide (see above)

VS Subjec tive Ur/Cr

CUE AND CLUE Male, 35 yo SOB DOE PND Hypertension since 5 years BP ; 170/90 RR 28 tpm PR : 100 bpm Pale conjungtiva Cardiomegaly Rh (+) in basal and medial Lab : Gfr : 4.61 Cxr : Lung edema, cardiomegaly Male, 35 yo SOB Cough with yellowish Low grade Fever RR 28 tpm PR : 100 bpm Tax : 37 8 Rh (+) in medial and basal area Leucocyte : 18,170 Cxr : Lung edema, Port score : 105

P List

INITIAL DIAGNOSE

PDx

PLANNING THERAPY

Pmo

3. HF st 3.1 Uremic C Fc IV cardiomyopath y 3.2 HHD

Echocardio graphy

O2 2-4 lpm nc Semifowler position Fluid balance Inj furosemide as above

VS subject ive

4. Lung 4.1. pneumonia infectio CAP n

Sputum culture and sensitivity test

Inj ceftriaxone 2 x 1 gr Inj levofloxacin 500 mg

VS subject ive

CUE AND CLUE Male, 35 yo General weakness Pale conjungtiva Lab : Hb : 7.3 Mcv : 85,7 Mch : 28,2 Gfr : 3,86

P List

INITIAL DIAGNOSE

PDx

PLANNING THERAPY

Pmo

5. 5.1. dt no 2 Anemia N-N

Blood smear

Plan give erythropoetin

VS subject ive

Male, 35 yo HTN since 5 years T : 170/90 Gfr : 3,86

6. HT st 6.1 primary II HTN 6.2 scondary HT 6.2.1 renal parenchimal

Funduscop y Lipid profile

Po : -amlodipin 10 mg -Furosemide (as above)

VS Subjec tive

Male, 35 yo K = 6.17

7. 7.1 due to no 2 hyperp otassem ia

Ca gluconas 1 amp Insulin short acting 10 iu D 40 % 2 flash

SE

THANK YOU

erythopoetin
Ninety-six percent of patients will respond to Epoetin at 450 units/kg/wk IV (a dose expected to produce a comparable response to 300 units/kg/wk administered SC103) within 4 to 6 months, provided that there are adequate iron stores.65 Therefore, an inadequate response to Epoetin therapy is defined as failure to achieve target Hgb/Hct in the presence of adequate iron stores at a dose of 450 units/kg/wk IV or 300 units/kg/wk SC within 4 to 6 months, or failure to maintain target Hgb/Hct subsequently at that dose. However, since there is a wide variability in dose response to Epoetin, an individual patient may respond to as little as 75 units/kg IV (or 50 units/kg SC) per week.