MORNING REPORT

Friday, November 1st, 2013

COASS IN CHARGE: DIANA BONTON WARDANITA KRISSANTIAS SUTANTO

MODERATOR: dr. DIDI CANDRADIKUSUMA, SpPD

Female/50y.o./W26

Summary of Data Base

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 the

abnormal kidney condition.

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.

Physical examination
BP = 140/90 mmHg PR = 120 bpm RR = 32 tpm, fast, deep GCS : 325 Tax : 39.1C Weight: 43kg Height:150cm BMI: 19.11

General appearance : looked moderately ill Head Neck Chest heart JVP R+ 3 cmH2O

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

Lymphonode enlargement(-)

Ictus invisible, palpable at 2 cm lateral ICS 5 S1, S2 single, murmur Symmetric, stem fremitus D = S Rh + + Wh - ++ - ++ - + Round, soefl(+),bowel sound N, liver span 8 cm, traubes space tympani, shifting dullness (+) Cold acral (+/+), edema (-)

lung

Abdomen Extremities

LABORATORY FINDING
LLab :
Hemoglobine Eritrocyte Leucocyte Hematocryte Thrombocyte MCV MCH Differential count Eosinofil Basofil Neutrofil 0.1 % 0-4 6.60 2.33 21.54 20.90 319 89.70 28.30 Result g/dL 106/L 103/L % 103/L fL Pg Normal Value 11.4-15.1 4.0-5.0 4.7-11.3 38-42 142-424 80-93 27-31

0.1
86.1

%
%

0-1
51-67

Limfosit

9.0

%
%

25-33
2-5

Monosit

4.7 -

Others

Lab

Result

Normal Value
0 32 0 33

SGOT
SGPT Ur Cr Na K Cl

39
25 110.90 5.40 125 3.94 102

U/L
U/L mg/dL mg/dL
mmol / L mmol / L mmol / L

16.6-48.5
<1.2 136 145 3.5 5.0 98 106

BGA PH

Value (Suplemental O 6 Lpm) 2 Blood Gas Analysis 7,35-7,45 7.50

PCO2
PO2 HCO3 O2 saturation Base Excess

28.5
163.2 22.5 95.2 -0.8

35-45 mmHg
80-100 mmHg 21-28 mmol > 95% -3 until +3 mmol

Conclusion

Urinalysis
Lab Value Yellow, cloudy 7.0 3+ 2+ 2+

Urinalysis Color
PH Leucocyte

Lab 10 x Epithelia Cylinder Hyaline Granular

Value 2.7 -

Nitrite
Protein Glucose Erythrocyte

40 x
Erythrocyte Keton urine Leucocyte 12.9 357.9

Urobilinogen
Bilirubin

Crystal
Bacteria

10207.0

ECG

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

CXR (31/10/2013)

CXR
AP position, asymmetric, KV too strong, enough inspiration Soft tissue thin, Bone normal Trachea in the middle Hemidiaphragm D is domeshape, S covered by cardiac imaging Phrenico costalis angle D/S covered by cardiac imaging Pulmo D/S: BVP increased, cotton wool appearance, cephalization Cor: site N, size CTR 62%, shape cardiac waist dissappear

Conclusion : cardiomegaly, uremic lung

Abdominal USG (19/02/2013)

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

CUE AND CLUE

Female/ 50 yo/w26 Decreased of conciousness Shortness of breath Fever Nausea and vomiting Diagnosed as CKD Diagnosed as nefrolitiasis

PL 1. Decrea se of concio usness

IDx 1.1 uremic lung 1.2 septic condition

PDx Urine culture and sensitivit y test Blood culture and sensitivit y test

PTx Oxygen 10 lpm NRBM Semifowler position Intravena fluid drip NS life line Intravena ceftriaxone 2X1 gram Nebulizer salbutamol 3X4 mg Hemodialysis CITO

PMo Complain VS Urine production

Pedu Cond ition, prog nosis

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 Ur/Cr110.90/5.40 eGFR 8.46 ml/mnt/1.73m2 BGA : severe hypoxemia Abdominal USG:Chronic parenchymatous renal disease bilateral

CUE AND CLUE

Female/ 50 yo/w26 Decreased of conciousness Fever Shortness of breath Nausea and vomiting Diagnosed as CKD Diagnosed as nefrolitiasis

PL 2. Septic condition 2.1

IDx

PDx Urine culture and sensitivity test Blood culture and sensitivity test

PTx Oxygen 10 lpm NRBM Semifowler position Intravena fluid drip NS life line Intravena ceftriaxone 2X1 gram Hemodialysis CITO

PMo Complain VS Urine production

Pedu

urinar y tract infecti on

Conditi on, progno sis

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

CUE AND CLUE

Female/ 50 yo/w26 Decreased of conciousness Shortness of breath Fever Nausea and vomiting Diagnosed 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

PL 3. Acute on CKD

IDx 3.1 obstructive uropathy 3.1.1 dt cystoma ovarii 3.1.2 nefrolithiasi s 3.2 PNC

PDx

PTx O2 10 lpm NRBM Bed rest Semifowler position Furosemide 400-0 Hemodialysis CITO

PMo VS Complain Urine production

Pedu Bed rest Prognosis

CUE AND CLUEM

Female/ 50 yo/w26 Shortness of breath Nausea and vomiting Diagnosed as CKD 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

PL 4 HF stage C FC III

IDx 4.1 uremic cardiomy opathy 4.2 anemia heart disease

PDx Echocar diograph y

PTx Oxygen 10 lpm NRBM Semifowler position Intravena furosemide 40 mg-0 -0

PMo Complain VS Urine production

Pedu Cond ition, prog nosis

CUE AND CLUE

Female/ 50 yo/w26 Fever Diagnosed as CKD Nausea and vomiting Decreased of appetite Lab: Albumine 2.50 mg/dL Proteinuria 2+

PL 5 Hypoalbu minemia

IDx 5.1 renal loss 5.2 hypercata bolic state

PDx

PTx Extra protein diet

PMo Complain Vital sign Albumine level

Pedu Condition Prognosis

Follow-up This Morning

GCS 425 BP 130/80 HR 100 bpm RR 24 tpm Urine output: 100 cc/hour

Thank You!