Morning Report

February, 14th 2016

Summary of Data Base

Anamnesis :
Mrs. Sujiati/45 yo/ W. 26
Chief complaint : Shortness of breath

Patient suffered from shortness of breath since six month ago,

intermittently but worsening in the last two days before
admission. In the last two days shortness of breath occurred when
she did heavy nor mild activity such as walk to the bathroom.
Shortness of breath somewhat relieved by rest but in the last two
days didnt relieved even she took a rest. She also slept on 3
pillows and in the half sitting position. She also often woke up in
the night because of shortness of breath.
She also suffered from nausea without vomiting since one
week ago, because of this condition she also suffered from
decrease of appetite, she only ate 5 6 spoon of rice and her
family reported that her body weight looked skinny.
She also complain about cough since two days ago with
whitish sputum especially in the morning since she suffered from
shortness of breath, and didnt accompanied with low grade fever

She often consumed the traditional poison if she felt pain after she worked.
She used to do it since she was young.
She was diagnosed end stage renal failure since six months ago, and got
routinely haemodyalisa two times per week every Monday and Thursday, the
last schedule of haemodyalisa about four days ago.
She also diagnosed with hypertension since one year ago, at that time the
blood pressure was 200/...but she didnt routinely controlled
She also complaint her passing urine was decreased since she diagnosed
with end stage renal disease, and the volume per day about 100 200 cc. No
history of diabetes mellitus
Past medical history :
In the last six months she hospitalized more than eight times at RSSA because
of shortness of breath
Family History :
Her mother suffered from hypertension
Social History :
She is a pensioner, married, she has two children.
Allergic history :
She doesnt have food and drug allergic
Medication History :
She routinely consumed irbesartan, furosemide, isdn, amlodipine, kalk (when
she underwent the hemodyalize)

PHYSICAL EXAMINATION
General appearance looked severely ill
BP= 234/140 mmHg
(ER) 210/80 mmHg
(ward)

GCS : 456

Tax : 36,6 0C
PR = 120 bpm (ER) 89 RR = 40 tpm
(ER) 28 tpm
bpm regular strong
(ward)
(ward)

Head

Conjunctiva Anemic (+)

Neck

JVP R + 4 cm H20 30
position

Thorax Heart

Ictus invisible & palpable at 2 cm lat ICS VI MCL S

RHM : SL D
LHM : ictus cordis
S1 S2 single, mur mur (regular), galllop (-)

Lung

Simetric SF D = S

Icteric (-)

ss v
v Rh + + (ER) Rh - s s bv bv
+ +
+ +
s s bv bv
+ +
+ +

Abdomen

Soefl, , BS + N, liver span 8 cm. Spleen impalpable, troube space

tympani, shifting dullness (-)

Extremities

Pitting Edema - /- Acral : warm and dry

+/+

LABORATORY FINDING (14-02-2016)

Lab
Leukocyte
Haemoglobi
ne
RBC
Trombocyte
Haematocri
t
MCV
MCH
Eo/Bas/Neu
/limf/Mon
SGOT

Value
(Normal)

Lab

Value

(Normal)

12990

4.700
11.300 /L

Natrium

133

136-145
mmol/L

7,20

11,4 - 15,1
g/dl

Kalium

4.29

3,5-5,0 mmol/L

4.0 5.0
106/L

Chlorida

107

98-106 mmol/L

2,4
260.000
22,30 %
90.70
29.30

142.000
Ureum
424.000 /L Creatinine
38 42 %

eGFR

80-93 f

GDS

27-31 pg

Calsium

0,5/0.2/81 0-4/0-1/51,0/15,8/2, 67/25-33/25

5
29

0-32 mU/dL

Osm

Albumin

94,20

20-40 mg/dL

9,37

<1,2 mg/dL

ml/min/1.72m2

271

<200

8.7

7.6-11.00
mg/dL

279

280 295
mosm/kg

4,26

3.5-5.5 g/dL

BGA with O2 10 lpm NRBM

(14/02/2016)
Value

Normal Value

PH

7.36

7.35-7.45

PCO2

29,7

35 45 mmHg

PO2

263,0

80 100 mmHg

HCO3

17,6

21 28 m mol/L

O2 sat Art

97,7 %

> 95 %

BE

-7,7

(-3) - (+3) m mol/L

Hb

6,9

True O2

55,39 mmHg

80 100 mmHg

Conclusion : acidosis metabolic fully compensated with

moderate hypoxemia

URINALYSIS February 14th 2016

LAB
Turbidity
Colour
PH
SG
Glucose
Protein
Keton
Bilirubin
Urobilinogen
Nitrite
Leucocyte
Blood

VALUE
Clear
Yellow
6,0
1025
Negative
3+
Negative
Negative
Negative
Negative
Negative
2+

LAB
10 x
Epithelia
Cylinder
Hyaline
Granular
40 x
Erythrocyte
Leukocyte
Crystal
Bacteria
Others

VALUE
5,2
Negative
-

3,1
6,7
501,3 x 10
-

ECG

CXR

CUE AND CLUE

PL

Idx

PDx

PTx

PMo

P
edu

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Dyspneu d effort
Paroxysmal Nocturnal
Dyspneu
Orthopneu
Nausea
Diagnosed as kidney
failure
Diagnosed as
hypertension
Physical
examination
GCS 456
BP 210/80 mmHg
PR 89 bpm
RR 28 tpm
Dry skin +
Anemia Conjunctiva
JVP = R + 4 cmH20
(30)
Cor: ictus ICS VI 2cm
MCL S
Murmur systolic grade
3/6 at all valve
Rhonki +/+
Edema +/+
UOP 500 cc/12 hour
Lab findings
Hb 7,38 gr/dL
Ur/Cr 94,20/9,37
mg/dl

1.
Shortnes
s of
breath

1.1 Acute Lung

Oedema
1.1.1
Accelerated
hypertensio
n
1.1.2 Heart
Failure
Stage C Fc
IV
1.1.3 Overload
syndrome

Echocar
diograp
hy

O2 10 lpm via NRBM

Semifowler position
Bed rest
Inj Furosemide 80 mg
IV continue with
Furosemide drip 20
mg/hour
Drip Nicardipine 5
15 mg/hour until MAP
decrease 25 %
(target 175/105
mmHg)
Negative fuid
balance 500 cc per
day
Hemodialysis Cito

VS
Comp
lain
Urine
produ
ction

Fluid
restri
ction,
expla
natio
n
about
renal
repla
ceme
nt
thera
py

CUE AND CLUE

PL

Idx

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Nausea
Diagnosed as kidney
failure
Diagnosed as
hypertension
Physical
examination
GCS 456
BP 210/80 mmHg
PR 89 bpm
RR 28 tpm
JVP = R + 4 cmH20
(30)
Cor: ictus ICS VI 2cm
MCL S
Murmur systolic grade
3/6 at all valve
Lab findings
Ur/Cr 94,20/9,37
mg/dl
eGFR 6
ml/mnt/1.73m2

2.
Hyperten
sion
Emergen
cy

2.1 Essential
(primary)
2.2 Secondary
2.2.1
Renoparenc
hymal
2.2.2
Renovascula
r

PDx

PTx

PMo

P
edu

O2 10 lpm via NRBM

Semifowler position
Bed rest
Drip Nicardipine 5
15 mg/hour until MAP
decrease 25 %
(within 1 hour)
(target 175/105
mmHg)
Per oral :
Irbesartan 0-0-300
mg tablet
Clonidin 3 x 0,15 mg
tablet

VS
(bloo
d
press
ure,
MAP)
Comp
lain

Disea
se,
comp
licati
on,
targe
t
treat
ment

CUE AND CLUE

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Dyspneu d effort
Paroxysmal Nocturnal
Dyspneu
Orthopneu
Diagnosed as kidney
failure
Diagnosed as
hypertension
Physical examination
GCS 456
BP 210/80 mmHg
PR 89 bpm
RR 28 tpm
Anemia Conjunctiva
JVP = R + 4 cmH20
(30)
Cor: ictus ICS VI 2cm
MCL S
Murmur systolic grade
3/6 at all valve
Rhonki +/+
Edema +/+
Lab findings
Hb 7,38 gr/dL
Ur/Cr 94,20/9,37 mg/dl
eGFR 6 ml/mnt/1.73m2
CXR: cardiomegaly
with congestive
pulmonum
ECG Left Ventricular

PL
3. Heart
Failure
stage C
FC IV

IDx

PDx

PTx

3.1 Hypertensive Echoca O2 10 lpm NRBM

heart
rdiogra Bed rest
disease
phy
Negative fuid balance
3.2 uremic
500 cc/day
cardiomyopa
Semifowler position
thy
Furosemide (as above)

Pmo
VS
Subj
Fluid
balance

P
edu
Disea
se,
treat
ment,
progn
osa

CUE AND CLUE

PL

IDx

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Dyspneu d effort
Paroxysmal Nocturnal
Dyspneu
Orthopneu
Nausea
Diagnosed as kidney
failure
Diagnosed as
hypertension
Physical
examination
GCS 456
BP 210/80 mmHg
PR 89 bpm
RR 28 tpm
Dry skin +
Anemia Conjunctiva
JVP = R + 4 cmH20
(30)
Cor: ictus ICS VI 2cm
MCL S
Murmur systolic grade
3/6 at all valve
Rhonki +/+
Edema +/+
UOP 500 cc/12 hr
Lab findings
Hb 7,38 gr/dL
Ur/Cr 94,20/9,37
mg/dl
eGFR 6

4.
Chronic
Kidney
Disease
stage 5
On
Routine
Hemody
alisis

4.1 HT
Nephroscler
osis
4.2 NSAID
Nephropath
y

PDx

PTx
O2 10 lpm via NRBM
Semifowler position
Bed rest
Negative fuid balance
500 cc
Iv plug
Renal Diet 1900
kcal/day Low salt < 2
g/day, Protein < 50
g/day
Furosemide drip 20
mg/hour
Per Oral :
Clonidine 3 x 0,15 mg
Irbesartan 0-0-300 mg
Hemodialysis Cito

Pmo

P
edu

VS
Comp
lain
Urine
produ
ction
Ureu
m
Creat
inin

Fluid
restri
ction,
expla
natio
n
about
renal
repla
ceme
nt
thera
py

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Diagnosed as kidney
failure
Physical
examination
GCS 456
Anemia Conjunctiva
Lab findings
Hb 7,38 gr/dL
MCV 90,70 f
MCH 29,30 pg

5. Anemia
Related
Chronic
Kidney
Disease

5.1 Anemia
Def EPO
5.2 Anemia
def Fe
5.3 Anemia
def B12
5.4 Anemia
def asam
folat

Blood
Smear
Reticulocyt
count
SI, TIBC,
Saturation
Transferin

Plan for
erytropoetin

CBC

Female/45 yo/ward
26

6.
Hyperglyce
mia state

6.1 Stress
Induce
Hypergli
cemic
State
6.2
Diabete
s
Mellitus
type 2

Fasting
Blood
Glucose
2 Hour Post
Pandrial
Blood
Glucose

Confirm the
diagnosed (wait
for the FBG and
2HPPBG)

FBG,
2HPP
BG

7.
Hyponatremi
a
hipoosmolar
hypervolemi
c

7.1 Volume
overloa
d

BJ Plasma
Electrolyte
urine

Furosemide as
above

SE
post
correc
tion

RBS : 271 mg/dL

Female/45 yo/ward
26
Anamnesis
Shortness of breath
Physical
examination
Rhonki +/+
Edema +/+
Natrium : 133 mmol/L

P edu
Diseas
e,
cause
of
anem,i
a,
treatm
ent,
diet,
complic
ation
Conditi
on,
treatm
ent

Diseas
e,
treatm
ent,
compli
cation

Thank You