Summary of Database

Mr. T /55 y.o/ JImbaran ward

Autoanamnese
Chief Complaint: tired easily
History of Present Illness:

• The patient is from Lavalate Hospital Referral Clinic for CAPD installation plan. Currently the patient complains of liquid feces 3x since 1 day

with a volume of 30-40x / defecation. Defecation does not spray and there is still pulp, mucus (-), blood (-).

• The patient was diagnosed with CKD since 1 year ago with initial complaints of swollen legs, nausea, and vomiting. Then when examined, it

was found that the patient had kidney failure and since then dialysis was performed 2 times / week every Tuesday and Friday using double

lumen access.

• The patient did not bring the supporting examination results from lavalatte hospital.

• Diagnosed with Gouty Arthritis since before being diagnosed with CKD but forgot the exact time, and taking allopurinol but not routinely

taken by the patient until now.

• Pain and swelling (-), no Fever, Chest Pain, Headache, Abdominal Pain.

• Defecation and Urination within normal limits, defecation +- 30-50cc/24 hours

 Summary of Database
Past Medical History:
There was no significant past medical history
Family History:
There is no family history of complaints/diseases like the patient.
Social History:
The patient used to work as a MC, last worked 6 months ago. Currently the patient lives with his children, wife and
siblings.
Review of System:
Pale
Urination about 400cc/day
Defecation within normal limit
 Physical Examination
General appearance moderately ill Sat O2 98% on room air
GCS 456 BW : 45 kg BH : 155 cm BMI : 18.9 (Normoweight)
UOP 50cc/24 hours ~ 0,2 cc/kgBB/hours
BP 90/66 mmHg PR 99 bpm regular strong RR 18 tpm Tax 36,8oC
Head Conjuctiva Anemic (+) , sclera icteric (-)
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing :
-|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-| - - |-
Cardio Ictus invisible, ictus palpable at lateral ICS V MCL S
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
Murmur (-), gallop (-)

Abdomen BU+N, Liver span 10 cm, traube’s space tympani, soefl

Extremities Pitting Edema minimal, tofus pedis digiti 1&2

 Laboratory Findings (21/12/2023)
LAB VALUE NORMAL LAB VALUE NORMAL

Hb 11 4.700 – 11.300 /µL Ureum 98,5 20-40 mg/dL

WBC 8.490 11,4 - 15,1 g/dl Creatinine 4,62 <1,2 mg/dL

Hct 35,5 38 - 42% eGFR 13,2 ml/min/1.73 m2
Plt 167.000 142.000 – 424.000 /µL
PPT 12,8 9.3-11.4 detik
MCV 89,9 80-93 fl
APTT 27,5 24.8-34.4 detik
MCH 27,8 27-31 pg
INR 1,25 0.8-1.30
Eo/Bas/Neu/ 5,8/0,2/62,9/22,9/7 0-4/0-1/51-67/
Limf/Mon ,2 25-33/2-5

HbSAg NR NR
AntiHCV NR NR
Na 138 136-145 mmol/L
K 4,87 3,5-5,0 mmol/L
Cl 99 98-106 mmol/L
Albumin 1,95
Electrocardiography (21/12/2023)
 Electrocardiography (21/12/2023)
• Sinus rhytm, HR 98 bpm regular
• Frontal Axis : Normoaxis
• Horizontal Axis : Normal rotation
• P wave : 0.08 sec
• PR interval : 0.12 sec
• QRS complex : 0.08 sec
• QT interval : 0.28 sec
• ST segment : isoelectric

Conclusion : Sinus Rhythm HR 98 bpm

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. CKD st 5 on HD - - Non pharmacology : PMo:
Mr. T /55 y.o/ JImbaran ward routine pro CAPD - Renal diet 1700 kcal/day, S,VS, UOP, Fluid
Subjective insertion protein 1.2gr/kgBB/day, low Balance
salt <2 gr/day
- The patient is from Lavalate Hospital PEd:
Referral Clinic for CAPD installation Pharmacology : Educate patient and
- IV plug family about what
plan - Pro CAPD insertion current CKD staging,
- The patient was diagnosed with - Backup HD during CAPD still how important CAPD
doesn’t work properly as renal replacement
kidney failure 1 year ago, and therapy and other
immediately having dialysis twice a complication of CKD
and how to manage
weeks it.
Objective :
H/N: Konjungtiva anemic (+)
BP 90/66 mmHg
UOP : 50cc/24 hours

Laboratory (21/12/23):
Ur/Cr : 98,5/ 4,62
eGFR : 13,2
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Anemia Normokrom - Non pharmacology : PMo:
Mr. T /55 y.o/ JImbaran ward Normositer Related - Diet 1.700 kkal/day, protein S,VS, Oxygen
Subjective Renal 1,0-1,2 gr/kgBW/day
- Feeling easily tired since 1 week hunger’s sign
ago, getting worse since two days Pharmacology :
ago, getting worse with activity, - Treat underlying disease
and relieved with rest. PEd:
- Plan to give SC Erythropoietin Educate patient and
- The patient was diagnosed with (EPO) 120 u/KgBW/week,
kidney failure 1 year ago, and family about relation
divide into 2-3 dose between anemia and
immediately having dialysis twice a (Transferrin serum>100 and
weeks CKD
Ferritin ≥20%
Objective :
H/N : anemic conjunctiva (+)

Laboratory 21/12/23 :
Hb: 11 g/dL
MCV / MCH : 89,9/27,8
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Chronic Gout Arthritis - - Non pharmacology : PMo:
Mr. T /55 y.o/ JImbaran ward - Diet 1.700 kkal/day, protein S,VS, VAS
Subjective 1,0-1,2 gr/kgBW/day
• Diagnosed with Gouty Arthritis Pharmacology : PEd:
- Treat underlying disease Educate patient and
since before being diagnosed with - PO Allopurinol 1x100 mg family about relation
between Gout
CKD but forgot the exact time, and Arhtritis and CKD
taking allopurinol but not routinely

taken by the patient until now.

Objective :
Extremities : Pitting Edema minimal,
tofus pedis digiti 1&2
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. Severe - - Non pharmacology : PMo:
Mr. T /55 y.o/ JImbaran ward Hypoalbuminemia dt - Diet 1.700 kkal/day, protein S,VS, VAS
Subjective Renal loss 1,0-1,2 gr/kgBW/day
- The patient was diagnosed with
kidney failure 1 year ago, and Pharmacology : PEd:
immediately having dialysis twice a - Treat underlying disease Educate patient and
weeks - Albumin transfusion 100cc family about relation
20% between
Objective : hypoalbumin and
Extremities : Pitting Edema minimal CKD
 Problem Analysis
Anemia

Decrease EPO
Production
Shortened RBC survival
Nutritional Deficiency (Iron, B12, Folic Acid)

Bone marrow suppression

Hyboalbumin CKD St 5 Chronic Gout

Reduced
synthesis and
Hyperuricemia Arthritis
increased
degradation
of albumin
MANAGEMENT ANALYSIS
PROBLEM THEORY FACTUAL
Chronic Kidney
Disease MANAGEMENT of CKD
(BASED ON PAPDI) On this patient

1. Specific Treatment for underlying

disease Renal Replacement
2. Prevention and treatment for comorbid Therapy
condition Routine Dialysis
3. Slow down the renal disease
progression
4. Prevent and treatment of
cardiovascular diseases
5. Prevent and treatment of complication
6. Renal replacement therapy such as
dialysis or kidney transplantation
 Risk Factor Analysis
PROBLEM THEORY FACTUAL
CKD st V Offer testing for CKD using eGFR
creatinine and ACR to people with any
of the following Risk Hypertension
Factors :
- Diabetes
- Hypertension
- acute kidney injury
- Cardiovascular disease (ischaemic
heart disease, chronic heart
failure, peripheral vascular
disease or cerebral vascular
disease)
- Structural renal tract disease,
recurrent renal calculi or prostatic
hypertrophy
- Multisystem diseases with
potential kidney involvement – for
example, systemic lupus
erythematosus
- Family history of end-stage kidney
disease (GFR category G5) or
hereditary kidney disease
- Opportunistic detection of
haematuria

NICE CKD Guideline

 Key Message Pathophysiology

From :
1. Schefold JC, Filippatos G, Hasenfuss G, Anker SD, Von Haehling S. Heart failure and kidney dysfunction: epidemiology, mechanisms and
management. Nature reviews Nephrology. 2016 Oct;12(10):610-23.
 Key Message Diagnosis

From :
1. Levin A, Stevens PE, Bilous RW, Coresh J, De Francisco AL, De Jong PE, Griffith KE, Hemmelgarn BR, Iseki K, Lamb EJ, Levey
AS. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the
evaluation and management of chronic kidney disease. Kidney international supplements. 2013 Jan 1;3(1):1-50.
Key Message Management
Key Message Management
 Key Message Social

• Educate the patient to keep the hygiene when do

dwelling CAPD
• Education have to be given to the patient and the family
about about the way to prevent contamination to CAPD
catheter and compliance in dwelling scheduled.
 Condition This Morning

• GA : Patient look mild ill, neated, personal hygiene good

(clean), can do normal activity, and on good mood
• BP : 101/68 mmHg
• PR : 88 bpm
• RR : 20 tpm
• Tax : 36,2
• SaO2 : 98% RA