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MORNING REPORTFriday, November 1st, 2013

COASS IN CHARGE:

DIANA BONTON WARDANITA

KRISSANTIAS SUTANTO

MODERATOR:

dr. DIDI CANDRADIKUSUMA, SpPD

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Summary of Data BaseFemale/50y.o./W26

Chief complaint: Decrease of consciousness

(Heteroanamnesis from her son)

The patient was unable to communicate with and tended to oversleep since one

day before admission and worsened the following day. At the beginning patient had

fever since 6 days before admission. The temperature got higher immediately and was

relieved with drug but got higher again. The fever was accompanied by nausea,

vomiting, cough, without diarrhea.

The patient vomited whenever she was eating or drinking. The food and drink

intake got lower.

The patient has been diagnosed with nephrolitiasis and cystoma ovarii since

2012. Initially the patient complained of back pain and underwent USG, which found

nephrolitiasis and ovarian cyst. The surgery dept. refused to remove the stone because

the patient had leg edema at the time and the patient was asked to undergo

hemodialysis. The obgyn dept. also refused to remove the cyst because of theabnormal kidney condition.

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The patient has been diagnosed with kidney failure since February 2013.

From February until September 2013 the patient underwent hemodialysis once a

week in RSSA. Since October 2013 the patient has undergone hemodialysis twice a

week.

History of medication: The patient was prescribed metoclopramide,

paracetamol, and a few other drugs from poli hemodialysis RSSA.

History of past illness: Patient has been admitted 3 times before:1. February 2013 because swelling at all of her body and diagnosed as

kidney failure then underwent hemodialysis

2. Mei 2013 to do AV-shunt surgery, but failed

3. September 2013 because decrease of conciousness and seizure

History of family: There is no history of kidney failure, kidney stone,

and hypertension in the patients family.

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Physical examination

BP = 140/90 mmHg PR = 120 bpm RR = 32

tpm, fast,

deep

Tax : 39.1C Weight: 43kg

Height:150cm

BMI: 19.11

General appearance : looked

moderately ill

GCS : 325

Head Pale conjunctiva (+/+), Icteric(-)

Neck JVP R+ 3 cmH2O Lymphonode enlargement(-)

Chest heart Ictus invisible, palpable at 2 cm lateral ICS 5

S1, S2 single, murmur -

lung Symmetric, stem fremitus D = S

Rh + + Wh - -

+ + - -+ + - +

Abdomen Round, soefl(+),bowel sound N, liver span 8 cm, traubesspace tympani,

shifting dullness (+)

Extremities Cold acral (+/+), edema (-)

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Lab Result Normal Value

SGOT 39 U/L 032

SGPT 25 U/L 033

Ur 110.90 mg/dL 16.6-48.5

Cr 5.40 mg/dL

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Blood Gas AnalysisBGA Value

(Suplemental O2 6 Lpm)

PH 7.50 7,35-7,45

PCO2 28.5 35-45 mmHg

PO2 163.2 80-100 mmHg

HCO3 22.5 21-28 mmol

O2 saturation 95.2 > 95%

Base Excess -0.8 -3 until +3 mmol

Conclusion

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UrinalysisLab Value Lab Value

Urinalysis 10 x

Color Yellow, cloudy Epithelia 2.7

PH 7.0 Cylinder -

Leucocyte 3+ Hyaline -

Nitrite- Granular -

Protein 2+

Glucose -

Erythrocyte 2+

40 xErythrocyte 12.9

Keton urine - Leucocyte 357.9

Urobilinogen - Crystal -

Bilirubin - Bacteria 10207.0

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ECG

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ECG

Sinus tachycardia, Heart rate 136 bpm

Frontal Axis : Normal

Horizontal Axis : clockwise rotation

PR interval : 0.12 QRS complex : 0.06

QT interval : 0.28

Conclusion : sinus tachycardia with HR 136 bpm

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CXR (31/10/2013)

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Abdominal USG (19/02/2013)

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Abdominal USG (19/02/2013)

Conclusion:

Cystic multilocular mass with septal and

internal echo left adnexa projected size

7.7x6.2x8.0

Minimal pleural effusion at left pulmo

Chronic parenchymatous renal disease

bilateral

Hydroureteronephrosis sinistra grade 1

Suspect agenesis right kidney DDx ectopic

P d

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CUE AND CLUE PL IDx PDx PTx PMo Pedu

Female/ 50 yo/w26

Decreased of

conciousness

Shortness of breath

Fever

Nausea and vomitingDiagnosed as CKD

Diagnosed as nefrolitiasis

PE: GCS 325

BP 140/90 mmHg

RR 32 tpm

Temp 39 C

Conj anemi +,

JVP = R + 4 cmH20Cor: ictus ICS VI 2cm lat

MCL S

Pulmo : Rh + in all area

of lung

Wheezing +

Shifting dullness +

Dry skin +Cxr: : cardiomegaly

Lab:

Hb 6.6 gr/dL

Ur/Cr110.90/5.40

eGFR 8.46

ml/mnt/1.73m2

BGA : severe hypoxemiaAbdominal USG:Chronic

parenchymatous renal

disease bilateral

1.

Decrea

se of

concio

usness

1.1 uremic

lung

1.2 septic

condition

Urine

culture

and

sensitivit

y test

Blood

culture

and

sensitivit

y test

Oxygen 10 lpm

NRBM

Semifowler position

Intravena fluid drip

NS life line

Intravena ceftriaxone

2X1 gram

Nebulizer salbutamol

3X4 mg

Hemodialysis CITO

Complain

VS

Urine

production

Cond

ition,

prog

nosis

CUE AND CLUE PL ID PD PT PM P d

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CUE AND CLUE PL IDx PDx PTx PMo Pedu

Female/ 50 yo/w26

Decreased of

conciousness

Fever

Shortness of breath

Nausea and vomitingDiagnosed as CKD

Diagnosed as nefrolitiasis

PE: GCS 325

BP 140/90 mmHg

RR 32 tpm

Temp 39 C

Conj anemi +

JVP = R + 4 cmH20

Lab:

Leucocyte 21.090

BGA : severe hypoxemia

UL: leucocyte 357.9 hpf

2. Septic

condition

2.1

urinar

y

tract

infecti

on

Urine

culture

and

sensitivity

test

Blood

culture

and

sensitivity

test

Oxygen 10 lpm

NRBM

Semifowler position

Intravena fluid drip

NS life line

Intravena ceftriaxone

2X1 gram

Hemodialysis CITO

Complain

VS

Urine

production

Conditi

on,

progno

sis

CUE AND CLUE PL ID PD PT PM P d

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CUE AND CLUE PL IDx PDx PTx PMo Pedu

Female/ 50 yo/w26

Decreased of

conciousness

Shortness of breath

Fever

Nausea and vomitingDiagnosed as CKD

Diagnosed as

nefrolitiasis

PE: GCS 325

BP 140/90 mmHg

RR 32 tpm

Temp 39 C

Conj anemi +,JVP = R + 4 cmH20

Cor: ictus ICS VI 2cm

lat MCL S

Pulmo : Rh + in all

area of lung

Wheezing +

Shifting dullness +

Dry skin +

Cxr: : cardiomegaly

Lab:

Hb 6.6 gr/dL

MCV 90.30

MCH 28.70

Ur/Cr110.90/5.40

eGFR 8.46

ml/mnt/1.73m2

BGA : severe

hypoxemia

3.

Acute

on

CKD

3.1

obstructive

uropathy

3.1.1 dt

cystomaovarii

3.1.2

nefrolithiasi

s

3.2 PNC

O2 10 lpm

NRBM

Bed rest

Semifowler

position

Furosemide 40-

0-0

Hemodialysis

CITO

VS

Complain

Urine

production

Bed rest

Prognosis

CUE AND CLUEM PL ID PD PT PM P d

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CUE AND CLUEM PL IDx PDx PTx PMo Pedu

Female/ 50 yo/w26

Shortness of breath

Nausea and vomiting

Diagnosed as CKD

PE: GCS 325BP 140/90 mmHg

RR 32 tpm

Temp 39 C

Conj anemi +,

JVP = R + 4 cmH20

Cor: ictus ICS VI 2cm lat

MCL S

Pulmo : Rh + in all area

of lungWheezing +

Shifting dullness +

Dry skin +Cxr: : cardiomegaly

4 HF

stage

C FC

III

4.1 uremic

cardiomy

opathy

4.2 anemia

heartdisease

Echocar

diograph

y

Oxygen 10 lpm

NRBM

Semifowler position

Intravena

furosemide 40 mg-0-0

Complain

VS

Urine

production

Cond

ition,

prog

nosis

CUE AND CLUE PL ID PD PT PM Pedu

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CUE AND CLUE PL IDx PDx PTx PMo Pedu

Female/ 50 yo/w26

Fever

Diagnosed as CKD

Nausea and vomiting

Decreased of

appetite

Lab:

Albumine 2.50

mg/dL

Proteinuria 2+

5

Hypoalbu

minemia

5.1 renal

loss

5.2

hypercata

bolic state

Extra protein

diet

Complain

Vital sign

Albumine

level

Condition

Prognosis

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Follow-up This Morning

GCS 425

BP 130/80

HR 100 bpm

RR 24 tpm

Urine output: 100 cc/hour

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Thank You!