Morning Report Friday, November, 8 2013

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Moderator : Physician In Charge: IA : dr. iwal, dr Yanti, dr Eldhy IB : dr. Betty, dr. Yasmita II : dr. Marthin III : dr. Sri Sunarti, Sp.PD

Summary Of Database: Mr A/45 Y.O/W 25

Chief Complaint: pro CAPD Patient presented with the chief complain want to insert CAPD History of past illness: Patient suffered from diabetes since 2 years ago, he had Hypertension since suffered form ckd, blood pressure usually 150-190/?. Patient diagnosed as CKD since 4, sometimes he felt shortness of breath that make him awake at night, he still abl to do daily activity independently History of medication: Patient on routinely HD since 4 months ago, 1x/week, got captopril, for his hypertension, there were no medication for his diabete,. She routinely controlled to nephrology department. Family History: his brother had kidney disease and passed away. Social History: No history of drink traditional medicine, he didnt work, had 2 children, Physical Examination BP= 130/90 mmHg PR= 104 bpm regular General App.: looked moderately ill Head Neck Thorax RR 18 tpm GCS : 456 Looked normoweight Icteric sclerae (-) Ax. Temp.= 35.8 C
0

Anemic conjunctiva (+) Lnn. Enlargement (-) 0 JVP : R + 5 cm H2O; 30 Cor Ictus invisible, palpable at 2 cm lateral ICS V, MCL S RHM S line D LHM ictus S1, S2 single, no murmur Pulmo Symmetric; SF D=S; S| S V | V Rh -| - Wh - | S| S V | V -|-| S| S V |V -| -|Flat, BS (N), liver span 8 cm, traube space tympany, flank pain D/S -, suprapubic pain -, soft, epigastric tenderness (-) Edema (-), warm acral

Abdomen Extremities

2( Dr. iwal)

LABORATORY FINDINGS (waiting for result) LAB RESULT Leukocyte Hemoglobine MCV MCH PCV

NORMAL VALUE 3,500-10,000/L 11.0-16.5 g/dl 80-97 m3 26.5-33.5 m3 35-50%

LAB Sodium Potassium Chloride Calcium Phospor RBS

RESULT

NORMAL VALUE 136-145 mmol/l 3.5-5.0 mmol/L 98-106 mmol/L 7.6-11 mg/dl 2.7-4.5 mg/dl >200 mg/dL 10-50 mg/dL

Thrombocyte

150,000390,000/l

Ureum

SGOT SGPT Diff count Eos/Ba/Neu/Ly/Mo Blood Gas Analysis PH pCO2 pO2 Bikarbonat (HCO3) Kelebihan Basa (BE) Saturasi O2 URINALYSIS

11-41U/L 10-41U/L

Creatinine Albumin eGFR

0.7-1.5 mg/dL 3.5-5.5 g/dL ml/m /1.73 m

2 2

7.35-7.45 35-45 80-100 21-28 (-3)-(+3) >95

Result SG pH Glucose 10X ephitel Silinder: Hyalin Granular other 40X Eritrocyte eumorfik dismorfik leucocyte Crystal bacteria

Result

Protein Keton Bilirubun Urobilin Nitrit Leucocyte Blood Epithel

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ECG: Sinus rhythim, HR : 100 bpm PR interval QRS complex QT interval Frontal Axis Horisontal Axis S in V2 + R in V5 >35 mm Tinvrted in v4-6 Conclusion : sinus rhytim, HR 100 bpm, LVH, iscemia anterolateral : 0,12 : 0,08 : 0,36 :Normal : normal

CUE&CLUE male/44 y.o Diagnosed CKD and undergo routine HD HT since 4 months ago History of diabetes since 2 years ago BP 130/90, PR 68, RR 30, T 35.8 C Ictus invisible, palp at ICS V 2 cm lat MCL S ECG: LVH male/45 yo History of HT and CKD BP: 130/90 mmHg

PL 1. CKD St 5 on HD Pro CAPD

IDx 1.1 Diabetic Nephropathy 1.2 GNC

PDx

PTx Equal Balance fluid (0cc/24hours) Venflon Renal DM diet: 1900Kcal/d; Low salt<2gr/d; protein 1-1.2 gr/KgBW/day, low potassium Pro CAPD

PMo S VS Urine Production

2. Hypertension St I

male/44 y.o Diagnosed CKD and undergo routine HD HT since 4 months ago History of diabetes since 2 years ago BP 130/90, PR 68, RR 30, T 35.8 C Ictus invisible,

3. HF St C Fc 2

2.1 secondary 2.1.1 renoparenchymal hypertension 2.1.2 renovascular HT 2.2 primary 3.1 Diabetic cardiomyopathy 3.2 HHD 3.3 Uremic cardiomyopathy

Funduscopy

Furosemid 3x 80 mg

S VS Target organ damage

Lipid profile, Echocardiograph y, Uric acid

Antihypertension as above

S VS

4( Dr. iwal)

palp at ICS V 2 cm lat MCL S ECG: LVH male/45 y.o History of diabetes since 2 years ago RBS 187 male/45 y.o -Diagnosed CKD PE: Conj anemis

4. DM type 2 normoweight

Diet as above

FBG, 2hpp BG

5. Anemia

5.1 due to chronic disease

Ferritin serum,SI,TIBC, blood smear, reticulocyte count

Folic Acid 1x3 tab B6/B12 3x1 tab

S VS Hb