Morning Shift Report Saturday, 30-11-2013 dr.

Dikara

Physician In Charge: 1A : dr. Dikara, dr. Yanti, dr. Eldi (cardio) 1B : dr. Diana, dr. Lya II : dr. Heri III : dr. Syifa M Sp.PD Summary of Data Base Male 27 yo/ w.25 Chief complain : General weakness (auto and heteroanamnesis with his father) Patient suffered from general weakness since today before go to RSSA for routine HD. Today, at HD room before doing HD blood pressure about 80/40 and he looks very weakness, because the BP decrease he suggested for hospitalized and post poned for HD He also complained shortness of breath when he doing mild activity and some times relived with rest. Some times woke up in the midnight due to shortness of breath, slept with 3 pillows with leg edema since 1 years ago He had ben diagnosed for kindey failure since 2 years ago and routine hemodialized twice per weeks (Wednesday and Saturday) History of hospitalized 3 weeks ago for 15 days, dignosed kidney failure, heart failure and also efusi perikard based on result of echocardiography. He had been discharge 3 days ago got furosemide 40mg, methylprednisolone (3x8mg), irbesartan (1x150mg), Codein (3x10 mg He also complained cough since 1 month ago, sometime with whitish sputum, without fever He also complained nausea and sometimes with vomiting since yesterday accompanied also decrease of appetite Physical Examination
Ward BP = 80/40 (HD) 80/50 (W)mmHg PR = 52 bpm, regular,weak RR = 26 bpm Takypneu GCS 356 Icteric sclera (-) Tax : 37,7C

General appearance looked severe ill Head Neck Chest Heart: Pale conjunctiva (+)

JVP R + 4 cmH2O 30 degree , insterted Double lumen Ictus invisible and palpable at ICS VI 1 cm lat MCL S LHM ictus RHM: SL D, marvel sound (+) S1, S2 single, murmur (-)

Lung:

Symmetric, SF D=S, normal percussion, Rh - - Wh - - - ++ - Soefl, bowel sound (+) normal, liver span 8 cm, traubes space thympani, shifting dullness ( - ) Leg edema +/+ , warm acral

Abdomen Extremities

Laboratory Findings (November 30th 2013)come after patient passed away

LAB Hemoglobin MCV MCH Leukocyte Eo/Bas/Neu/Limf /Mon PCV Trombocyte UA VALUE 6.40 77.30 24.20 35.810 0.1/1.0/88.0 /3.0/1.0 20.40 200.000 12.6 NORMAL 11,0-16,5 g/dl 80-96 fl 26,5-33,5 pg 3.500-10.000/L 0-4/0-1/51-67/2533/2-5 35-50% 150.000-390.000/L 3.4- 7.0 mg/dl LAB RBS Ureum Creatinine Natrium Kalium Chlorida albumin VALUE 90 263.10 8.06 129 6.29 101 2.58 NORMAL < 200 mg/dl 10-50 mg/dL 0,7-1,5 mg/dL 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L 3.5-5.5 g/dl

CXR ( November 30th 2013 )

AP position, asymmetric, enough KV, enough inspiration Soft tissue and bone: normal Trachea in the middle Sinus phrenicocostalis dextra and sinistra covered by cardiac shadow Hemidiaphragma dextraand sinistra covered by cardiac shadow Lung: difficult to evaluated Cor: site N, shape: neck bottle, size: CTR= more than 70% Conclusion: Cardiomegaly and suggested cardiac tamponade

BGA November 30th 2013 come after patient passed away

PH : 7.29 (N: 7.35-7.45) PCO2 : 43.2 mmHg (N: 35-45) PO2 : 55.3 mmHg (N: 80-100) HCO3 : 19.1 mmol/L (N: 21-28) O2 Sat Arterial: 85.2% (N > 95) BE: -6.5 mmol/L Conclusion: respiratory failure tipe I ECG ( November 30th 2013 ) Sinus rhytm with HR 105 bpm Frontal Axis : Norml Horizontal Axis : Normal PR interval : 0.18 QRS complex : 0,08 QT interval : 0,34 QS pattern V1-V2 T inverted at II, III, AVF Conclusion : Sinus tachycardia with HR 105 bpm, ischemic inferior and OMI anterior

CUE AND CLUE Male/ 27 yo/W. 25 A General weakness Diagnosed CKD since 2 years ago Routine HD twice/weeks PE GCS 456 TD: 80/50 N: 52 weak RR: 26 takypenu T: 37.7 Lab: Hb: 6.4 Leu: 35.810 Trombo: 200.000 HT: 20.40 RBS: 90

PL 1.Shock Condition

IDx 1.1Cardiogeni c shock 1.1.1 Cardiac tamponade 1.2 Hypovolemic shock 1.2 Septic shock

PDx Inserte d CVP

PTx O2 8-10 LPM NRBM At HD: Rehydration/loading NaCl 0.9% 250cc AT Ward: Drip Dobutamin 220mcg/kgbw/min

PMo

PEd

VS, Therapy Urine produ ction,

Male/ 27yo/W. 25 A Diagnosed CKD since 2 yeras ago Route HD twice/week Nausea Vomiting SOB PE: GCS 456 BP: 80/40 PR: 52 RR: 26 takypneu Edem (+/+) Lab: Hb: 6.40 Ur: 263.10 Cr: 8.06 Ua:12.6 Male/27 yo/W. 25 A: Diagnosed CKD on HD since 2 years ago History of HT uncontrolled since HD SOB Dypsneu on effort PND PE GCS 456 BP: 80/40 PR: 52 Weak RR: 24 takypneu Ictus palpable at ICS VI 1 cm lat MCL S Lower extremitas edem (+/+) ECG: sinus tachycardia HR 105 bpm , ischemic inferior, and OMI anterior CXR: Cardiomegaly suggested cardiac tamponade Male/27yo/W. 25 A:

2.CKD st 5 on HD

2.1 toxic agent dt energy drink (extra joss) 2.2 HT Nefropathy

O2 8-10 LPM NRBM Bed rest Fluid balance negative 0 cc/d durante shock condition Kidney Diet 1700kcal/d Low salt <2gr/f Protein 50gr/d Inj. Fursemide 40-0-0mg (post poned)/BPS>100mmHg Inj. Metoclopramide 3x10 mg (prn) HD elective if BPS>100mmHg

Prod Therapy, urine, HD S, VS, Ur, Cr

3. HF ST C FC IV

3.3 Uremic cardiomyopat hy 3.2 HHD

Echoca rdiogra phy

O2 2-4 LPM NRBM Semifowler potition fluid balance negative 0cc/24h durante shock condition Lowsalt <2gr/d Inj. Furosemide as above (post poned)

S, VS, Avoid Urine heavy produ activity ction

4 Cardiac tamponad e

4.1Uremic pericarditis dt o 2

O2 4 lpm Nasal canul Bed rest Semifowler potition

S, Vs, Therapy Urine and produ prognosi

 History Efusi perikard before from Echo Diagnosed CKD since 2 years ago SOB General weakness PE: BP: 80/40 PR: 52 weak RR: 24 JVP R+4 Cm H2O Marvel sound (+) CXR: cardiomegaly and suggested cardiac tamponde ECG: sinus tachycardia with HR 105 bpm, OMI anterior wall Male/27yo/W. 25 A: Diagnosed CKD since 2 years PE: Pale conjungtiva (+) Lab: Hb: 6.40 MCV: 77.30 5. Anemia HM 5.1 Chronic disease dt CKD st 5 5.2 def FE 5. 3 Def folic acid 5.4 Def EPO Reticul osit count, SI, FE TIBC

ction Consul cardiology cito

Tranfision PRC 2 kolf durante HD with target HB>8mg/dl

S, VS , CBC

MCH: 24.20
Male/27 yo/W. 25 Lab: K:6.29 RBS: 90 6. Hyperpota semia

6.1 dt no 2

Inj. Ca glukonas 1 amp IV Inj. D40 2 flash IV Inj. Rapid acting insulin 10 iu IV

SE level, ECG

therapy

Time: 11:00 GCS 356 BP: 80/40 RR: 24 PR: 52 weak T: 37.8 Drip dobutamin(2-20mcg/kgbw/min) O2 8-10 lpm NRBM PO: inj. Antrain intravena Thorax and ECG cito at ER with high risk, KIE (+) BGA: waiting result DL, Ur, Cr, SE, Albuin, OT, PT waiting resul

11:15 GCS 346 GCS 356 BP: 80/40 RR: 28 PR: 50 weak T: 37.5 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

11:30 GCS 356 BP: 80/50 RR: 32 PR: 88 weak T: 37.5 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

11::45 GCS 346 BP: 80/50 RR: 32 PR: 92 weak T: 37.3 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

12:00 GCS 346 BP: 90/50 RR: PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

12:15 GCS 346 BP: 90/50 RR: 36 PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

12:30 GCS 346 BP: 90/50 RR:38 PR: 90 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

12:45 GCS 346 BP: 90/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutamni(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM

13:00 GCS 346 BP: 110/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutami(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM Consult to cardiology for cardiac tamponade

13:15 GCS 346 BP:110/50 RR: 38 PR: 98 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM

13:45 GCS 346 BP:110/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM

14:00 GCS 346 BP:90/40 RR: 31 PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued increase O2 8-10 lpm NRBM

14:15 GCS 233 BP:80/palpatoar RR: 16 PR: 20 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued increase O2 8-10 lpm NRBM

14:20 GCS 111 BP:difficult to evaluated RR: - PR: - weak T: 36.9 Bagging, CPR 30:2 Inj. Adrenalin 1 amp IV

14:30 patient passed away