Resident on duty : dr. WahyuCoass on duty : Monica, KaraSupervisor : dr Soroy Lardo SpPD FINASIM

DUTY REPORTFEBRUARY 5TH 2014

CKD AND HHD

DEPARTMENT OF INTERNAL MEDICINEINDONESIA ARMY CENTRAL HOSPITAL GATOT

SOEBROTO

PATIENT RECAPITULATION

Ward : 2 new patients

6th floor : 1 new patientMr. JL, 42 yo, Dx: observation on febris day 5 ec DHF dd/ Typhoid fever.5th floor : 1 new patientMrs. SS, 48 yo, Dx: CKD stage V with anemia normocytic normochrom and acidosis metabolic; hyperkalemia; CHF fc II ec HHD4th floor : -3rd floor : -

PATIENT’S IDENTITY

Name : Mrs. SSSex : FemaleAge : 48 years oldJob : HousewifeReligion : MoslemMarital Status : MarriedAddress : Perumahan Graha Prima Blok

Mawar 27 No 18 Bekasi

ANAMNESIS

Autoanamnesis on February 5th 2014 at 10.30 PM

Chief Complain:General weakness since Monday

Additional Complain:Dry cough

CURRENT ILLNESSPatient was admitted to ward with general

weakness since Monday. Her complain became worsen day by day and she couldn’t continue her daily activities.

She also complained of having dry cough without blood since Monday. She denied any fever, shivering, night sweat and unexplained weight loss.

There was history of dyspnea 2 days ago, DOE (-), OP (-), PND (-), chest pain (-), excessive sweating (-), nausea (-) and vomiting (-).

There was also history of swollen legs 4 days ago. There were no complains of micturition and defecation, the quantity are within normal limit. Fluid balance of input and output was equal.

CURRENT ILLNESSPatient was diagnosed with Chronic Kidney

Disease stage V. She was suggested to have hemodialysis but she refused because she thought that she is in good condition.

She suffered hypertension for 4 years and take routine medications with Amlodipine 1 x 10 mg and Valsartan 1 x 160 mg.

Past Medical HistoryDiabetes (-)Cardiac disease (-)Allergy (-)

No family member with the same symptom Hypertension (-)Diabetes (-)Cardiac disease (-)Allergy (-)

Family Medical History

PHYSICAL EXAMINATIONVITAL SIGNSConsciousness :Compos MentisGeneral State : Moderate SicknessBlood Pressure :130/100 mmHgHeart Rate : 112 x/minute, regularRespiratory Rate : 22 x/minute, regularTemperature : 37,9oCBody Weight : 42 kgBody Height : 150 cmBMI : 18.6 (normoweight)

PHYSICAL EXAMINATIONGeneral Examination

Head : NormocephalEye : anemic conjunctiva (+/+), icteric sclera (-/-)Ears : normotia, discharge (-)Nose : septum deviation (-), discharge (-)Mouth : pale lips, normal tongue, hyperemic pharynx

(-), T1-T1Neck : lymph nodes enlargement (-), JVP 5-2 cmH2O

Thorax : normothorax, symmetric, intercostal retraction (-)Cor :Inspection : ictus cordis was not visiblePalpation : ictus cordis palpatedPercussion : right cardiac margin at 5th ICS parasternal

dextra line,upper cardiac margin at 3rd ICS parasternal sinistra line and left

cardiac margin at 5th ICS anterior axillary line. Auscultation : regular 1st and 2nd heart sound, murmur (-),

gallop (-) Pulmo : vesicular breathing sounds, rhonchi (-/-), wheezing

(-/-)

Abdomen : flat, soft, tympani, no enlargement of liver & lien, bowel sound normal, tenderness (-)

Extremities : warm, pitting edema (-), cyanosis (-) CRT < 2 seconds

DIAGNOSTIC PLANS

RESULT NORMAL RANGE

Hb 6.8 13 - 18 g/dl

Ht 20 40 – 52 %

Erythrocyte 2.3 4.3 - 6.0 mil /ul

Leukocyte 6800 4800 - 10800/ul

Thrombocyte 183000 150000 - 400000/ul

MCV 87 80 – 96 fL

MCH 30 27 - 32 pg

MCHC 34 32 – 36 g/dL

LABORATORY TESTS (Feb 5th 2014, 08.50 AM)

RESULT NORMAL RANGE

Ureum 232 20-50/ mg/dL

Creatinine 3.8 0.5-1.5 mg/dL

Random blood glucose

107 <140 mg/dL

Na 140 135-147 mmol/L

K 5.3 3.5 – 5.0mmol/L

Cl 105 95-105 mmol/L

Feb 5th 2014, 7.28 PM

Blood gas analysis

RESULT NORMAL RANGE

pH 7.287 7.37-7.45

pCO2 18.3 33-44 mmHg

PO2 132 71-104 mmHg

HCO3 8.8 22-29 mmol/L

BE -15.7 (-2)-3 mmol/L

O2 Saturation 94.9 94-98%

AGDFeb 5th 2014, 9.50 AM

Rontgen ThoraxCardiomegaly (CTR

55%)

ECG

ECG

ECG

ECGSinus rhythm, normoaxis, P wave normal,

QRS rate 94 bpm, PR interval 0.09 s, QRS complex 0.06 s, ST changes (-), T inverted on V1 and V2, AV block (-), BBB (-), LVH (+), RVH (-) and prolonged QT (0.4 s).

RESUMEA patient, female, 48 years old, was admitted with general weakness since Monday. There was dry cough. There were history of dsypnea, DOE (-), OP (-), PND (-) and swollen legs.

Patient was diagnosed with CKD stage V but she refused to undergo hemodialysis. Patient was diagnosed with hypertension for 4 years and take routine medications (Amlodipine and Valsartan).

Vital signs showed BP 130/100 mmHg, tachycardia (112 bpm) and febris (37.9oC). On general examination, there were anemic conjuctivas, dry lips and left cardiac margin at 5th ICS anterior axillary line (shifting to the left). The laboratory findings showed anemia (Hb 6.8), eritropenia (2.3), increased ureum (232), increased creatinine (3.8), hyperkalemia (5.3) and acidosis metabolic. The radiologic finding showed cardiomegaly.

PROBLEMS LIST

1. CKD stage V with anemia normocytic normochrom and acidosis metabolic

2. Hyperkalemia3. CHF fc II ec HHD

ASSESSMENT

1. CKD stage V with anemia normocytic normochromBased on:Anamnesis : general weakness, history of dyspnea and swollen legs.Physical examination : anemic conjuctivasLaboratory findings : anemia (Hb 6.8), eritropenia (2.3), increased ureum (232), increased creatinine (3.8); CCT 14.4, AGD: acidosis metabolic (pH/pCO2/pO2/HCO3/BE:7.287/18.8/132/8.8/-15,7)

2. HyperkalemiaBased on:

Laboratory findings : hyperkalemia (5.3)

3. CHF fc II ec HHDBased on:

Anamnesis : swollen legs, patient suffered hypertension for 4 years and take routine medications with Amlodipine 1 x 10 mg and Valsartan 1 x 160 mg.

Physical examination : 130/100 mmHg, left cardiac margin at 5th ICS anterior axillary line (shifting to the left)Rontgen thorax : CTR 55%, ECG : LVH (+)

THERAPYDiagnostic planEchocardiogram

Monitoring planElectrolyte post GIC admissionCheck Hb post transfusion Check blood gas analysis post BicNat therapy

Therapeutic planGradually PRC transfusion 500ccGlucose D40 50cc + Insulin 10unit IV + Ca Gluconas 1amp (GIC)

BicNat 100mEq for 4 hoursLasix 3x2ampKalitake 3x1sacchetAmlodipine 1x10mgValsartan 1x160mg

PROGNOSIS

Qua ad vitam : Dubia ad bonamQua ad functionam : Dubia ad malamQua ad sanationam : Dubia ad malam

THANK YOU