Coass IN CHARGE:
Faizal Reza Pahlevi
Sri Lestari Fajrien
Social history:
He married, had 2 children. He smoking since youth about 12 bars/day and
stop about 15 years ago. He work as labour but already retired since 6 years
ago.
About 1-2 year before he diagnosed kidney failure, he often consume energy
drink such as extra joss or kukubima , about 3X/week and also traditional
potion jamu udekan about 1x/week.
Physical examination
General appearance looked moderetely ill, Oxygen GCS 456
nasal canule 2-4 lpm, Looked normoweight
BP 140/80 mmHg RR 21 times/minute
PR 100 beat per minute regular strong Temp 36.7 C
Head Pale conjunctiva + Icterus Sclera -
Chest Heart: Ictus invisible and palpable at ICS VI 1 cm lat MCL Sinistra
LHM ≈ ictus, heart waist (-)
RHM: SL D
S1, S2 single, murmur (-)
Lung: Symetric, SF D= S s s Rh - - Wh - - V V
s s -- - - VV
s s ++ --
Abdomen Rounded, bowel sound ( +) normal,
liver span 7 cm, traube space dullness, undulation (+), tender pain in all area of
abdomen
Genitourinary
Extremities pale +/+ , dry skin +, Capillary refil time < 2 second, edema (-)
Lab Value Lab Value
Leukocyte 13.190 3.500-10.000/µL Natrium 128 136-145 mmol / L
126
Haemoglobine 8.10 11,0-16,5 g/dl Kalium 6.12 3,5-5,0 mmol / L
MCV 84.50 80-97 fL 5.40
MCH 26.60 27-31 pg Chlorida 102 98-106 mmol / L
101
PCV 40.40% 35-50% RBS 109 < 200 mg/dL
Trombocyte 379.000 150.000- SGOT 9 11-41U/L
390.000/µL
Eo/Ba/Neu/Ly/ 0.8/0.2/82 0-4/0-1/51- SGPT 8 10-41U/L
Mo .6/9.9/6.5 67/25-33/2-5
Ureum 188.80 10-50 mg/dL Albumine 3.31 3.5-5.5
PH 7.36 7,35-7,45
Microscopic
-Glucose 1 Mg/dL
-TG 9 Mg/dL
-cholesterol -2 Mg/dL
BOF: no sign of
perforation
Lab:
Leucocyte 13.900 u/L
Asites fluid analytic :
PMN 1963 /uL
LDH 3223 U/L
Rivalta test (-)
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Hemodialysed
elective
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Male/48 yo 3. CKD 3.1 GNC Renal Soft diet 1700 Urine Condit
History taking : stage 5 on 3.2 NSAID biopsy kcal/day low salt < 2 production ion,
Diagnosed as kidney routine nephr gram/day, protein 55 progno
failure
Routinely hemodialysed
HD opathy gram/day SE sed
1 time/week 3.3 PNC
History of consume Hemodialysed Ureum and
energy drink and elective creatinin
traditional potion
Physical examination:
Conjunctiva anemis (+)
Pale extremities (+)
Dry skin (+)
Undulation (+)
Lab:
Hb 8.10 gr/dL
MCV : 84.50 fl
MCH: 26.50 pg
Ur/Cr 181.80
/19.90mg/dL
eGFR 3.5
ml/minute/1.73m2
SE 128/6.12/102
mmol/L
Albumine 3.31 gr/dL
UL :
Protein 2+
Erythrocyte 115.3 hpf
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PE:
Undulation (+)
Lab:
Ur/Cr 181.80
mg/dL
eGFR 3.5
ml/minute/1.73m2
SE 128/6.12/102
mmol/L
Osm 260
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Lab:
Leucocyte 13.190
/uL
UL
Nitrit (+)
Erythrocyte 115.3
hpf
Eumorfic 85%
Leucocyte 2395,7
hpf
Bacteria 480.9 X
10*3
Fungi (+)
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Lab:
Ur/Cr 181.80 /19.90
mg/dL
Thank You!