MR FAI-31 CKD.pptx

8/13/2019 MR FAI-31 CKD.pptx

1/13

MORNING REPORT

Friday, July 15 th2011

PHYSICIAN INCHARGE:

IA: dr. Rifai, dr. Yuni, dr. BagusIB: dr.Angga, dr. Didin

II : dr. Fatma

III: dr. C Singgih W, SpPD

Moderator : dr. Gatoet Ismanu, SpPD KPTI


2/13

SUMMARY OF DATA BASEMr. M/15yo / w. 22

Chief complaint:

vomitingPatient suffered from vomiting since 4 days before admission, about 3

time per day or every meal, contain residual food and water, with

volume glass, and the last days accompanied with coffee ground

vomiting just 1 time about glass, without epigastrial pain. So, he

had decrease of appetite.

He also complain about swelling all of his body since 1 month ago,

gradually from his feet and referred until his face.

Already diagnosed with renal disease after discharge at word 27

RSSA but after that he didnt controlled routinely, because he always

refuse for check his condition to the RSSA and the last medication he

got furosemid, captopril, and folic acid.


3/13

Physical ExaminationGeneral

appearance

Looked midly ill, GCS 456

W: 60 kg H: 158 cm BMI:24 kg/m2

Blood Pressure 130/80 mmhg

Pulse Rate 88 bpm, strong regular

Respiration rate 24 tpm (W)

T ax 36.2C

Head Anemic (+ ),Icteric (-), face edema, NGT + cofee ground

Neck JVP R + 0cm H2O

Thorax

Heart

Ictus invisible palpable in MCL S ICS V

RHM sternal line D, LHM as Ictus

S1 S2 single, murmur -

Lung

After HD

Insp: D=S

Symmetric

Palp:

Stemfremitus

D=S

Perc: S S

S S

S S

Ausc: V V rh: - - wh: - -

V V - - - -

V V - - - -

Abdomen Flat ,Soefl, Liver span 8 cm, troube space tympani , BS (+) N,

epigastic pain (-) , meteorismus (-)

,Extremities Leg Oedem +, pale +, RT (-)


4/13

Laboratory findingLab Value Lab Value

Leucocyte 8.100 /L Na 135 Mmol / L

Haemoglobin 3.3 g/dl K 4.7 Mmol / L

MCV 81 um3 Cl 107 Mmol / L

MCH 29.6 pg OT 18 U/L

PCV 9.0 % PT 15 U/L

Thrombocyte 230.000 /L Albumin 2.18RBS 130 mg/dL

Ureum 285.9 mg/dL

Creatinin 26.98 mg/dL

eGFR3.82

urinalysis

SG =1.015 PH = 6.0 Ketone (-) Nitrite:(-) Crystal (-) Bactery:

( )

Glucose (-) Protein :( +4) Ery (+3 ) Ery : ( 10-15 )hpf Leuco : (- ) ( 5-10 hpf)


5/13

ECG


6/13

ECG

Sinus rhythm, HR : 86 tpm

PR interval : 0.12

QRS interval :0.08

QT interval :0.4

Frontal Axis : Normal

Horizontal Axis : normal

Conclusion : Sinus rhythm with HR 86 bpm,


7/13

CXray( june 23 th 2011)


8/13

CXray( june 23 th 2011)

Thorax PA, symmetric, lessinspiration, bone and soft tissue

normal, sinus phrenico costalis R and

L sharp, hemidiaphragma R and Ldome shape, trachea in the middle,

Lung normal

Cor: Site, shape normal size: 50% Conclusion: normal CXray


9/13

CUE AND CLUE PROBLEM

LIST

INITIAL

DIAGNOSE

PLANNING

DIAGNOSE

PLANNING THERAPY PLANNING

MONITORING

1.M/15 yo

Ax:

Patient suffered from vomiting

the last days accompaniedwith coffee ground vomiting

just 1 time about glass,

decrease of appetite

swelling all of his. Already

diagnosed with renal disease

didnt controlled routinely, the

last medication he got

furosemid, captopril, and folicacid. Some time he also felt

shortness of breath if he done

a hard work, and the SOB

became relived with rest.

PD:

RR: 24 tpm , conjungtiva

anemic, edema at face,leg, extremity looks

pale

Lab;

Hb: 3.3, ur/cr : 285.9/

26.98, eGFR: 3.8,

albumin 2.18,

proteinuria: +4,eritrocituria+3,

1. CKD st

5

1.1 GNC

1.2 PNC

Renal

biopsy

-. Renal diet 1700

kcal/day with protein

0.6-0.8mg/kg/day,

low salt < 2 gr/day,cholesterol


10/13


LIST

INITIAL

DIAGNOSE

PLANNING

DIAGNOSE


MONITORIN

G

2 M/15 yo

Ax:

Patient suffered from

vomiting the last days

accompanied with coffee

ground vomiting just 1

time about glass,

PE:

BP 130/80, PR: 88 tpm

RR: 24 tpm, conjungtivaanemia +, extremity

looks pale, NGT + coffee

ground

Lab;

Hb: 3.3, MCV 81

MCH 29.6, ur/cr :

285.9/ 26.98, eGFR:3.8,

2. Upper

GI

bleeding

2.1 uremic

gastropathy

Endoscopy -. NGTgastric lavage

per 8 hr, 1 time negatif

fluid diet.

-. Bolus omeprazole

80 mg continous with

drip omeperazole 8

mg/ hr until 72 hr or

bleeding was stop

Bleeding, Hb


11/13


LIST

INITIAL

DIAGNOSE

PLANNING

DIAGNOSE


MONITORIN

G

3 M/15 yo

Ax:

Patient suffered from

vomiting the last daysaccompanied with coffee

ground vomiting just 1

time about glass,

PE:

conjungtiva anemia +,

extremity looks pale,

NGT + coffee groundLab;

Hb: 3.3, MCV 81

MCH 29.6, ur/cr :

285.9/ 26.98, eGFR:

3.8,

3. Anemia

Normo

Normocyter

4.1 due to

CKD

4.2 due to

upper GIbleeding

Retyculocyte

count

-.plan PRC tranfusion Hb

4. M/15 yoAx: decrease of appetite

swelling all of his. Already

diagnosed with renal disease

didnt controlled routinely,

albumin 2.18, proteinuria: +4,

4.hypoalbumin

4.1 renal loss Proteinesbach

-protein diet 0.6-0.8mg/kg/day, +

protein ebach

Complain,albumin serum


12/13


13/13

MR FAI-31 CKD.pptx

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