AFTERNOON REPORT

CASE Dec 7,2017

PATIENT’S IDENTITY
Initial : RKNM
Age : 53 y.o
Gender : Female
Ethnicity : Balinese
Religion : Hindu
Address : Panjer
Marital Status : Married
Med. Record : 01311242
Time of Arrival : Dec 6, 2017. 22.31 pm
ANAMNESIS
Chief complain : right waist pain
Present history :
• Patient came accompanied with families to RSUP Sanglah with chief
complaint right waist pain since 2 weeks ago, and getting worse untill
the patient couldn’t stand anymore since 1 day BATH. The pain was
said happened suddently and didn’t get any better with traditional
medicine which had been taken to the patient’s skin before. The patient
said it would be so much painfull even when someone just slightly
palpate on the waist. The pain is fluctuating and spread from the waist
area down into right lower abdomen.
• Her daughter said that the patient also often felt weakness since 2
weeks ago. Patient felt weakness all over the body until patient unable
to walk.
• Altered of consciousness, limb swelling, shortness of breath, fever,
cough, headache were denied. Patient said there were no problem
ANAMNESIS
 Past illness history :
Patient has been diagnosed with CKD since 2014. Patient had a
history of HD 9 times and the last one was 2 years ago at
Sanglah Hospital (patient and family forget the exact time was).
Patient had been planned for regularly hemodialysis, but had
choosen to reject it because she cant stand on the pain of the HD
process.
Patient also had a history of Hypertension since 14 years ago,
and taking Captopril regularly 2 times a day (family doesnt know
the mg of the pill given). History of Diabetes Melitus, cardiac
disease were denied.
Patient also had been told that she had a wet lung, about 3
months before, with chief complain shortness of breath (didnt
appeared on this time).
ANAMNESIS
 Family history :
None of patient family member had the same complaint.
History of kidney disease and heart disease on her family was
denied.

 Social and Personal History :

Patient only does light activities at home.
History of alcohol comsuption and smoking was denied.
 PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : E4V5M6

Vital Sign:
BP : 180/100 mmHg
RR : 20 x/mins
HR : 71 x/min
Tax : 36.7ºC
SpO2: 98% on room air
Bw : 35 kg
H : 150 cm
BMI : 15,6 kg/m2
PHYSICAL EXAMINATION
Eyes : conjunctiva anemis; icterus, reflex pupil, edema palpebral couldn’t be
examined
ENT : Tonsils T1/T1; pharyngeal hyperemia (-); dry lips (-)
Neck : JVP PR + 3m cmH2O; lymph node enlargement (-)
Thorax : Symetric
Cor:
Inspection : Ictus cordis unseen
Palpation : Ictus cordis on ICS V, 2 fingers right away from MAL
Percussion :
CW : ICS II Sinistra, 2 fingers left away from PSL
LB : ICS V Sinistra, 2 fingers right away from MAL
RB : ICS IV, PSL Dextra
Auscultation : S1 S2 normal regular, murmur (-)
 PHYSICAL EXAMINATION
Pulmo
Inspection : Symetric (static and dynamic)
Palpation : Vocal Fremitus n/n
Percussion : sonor/sonor - - - -
Auscultation : vesicular + + , Rh - - , wh - -
+ + - - - -
Abdomen : + +
Inspection : Distention (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani, Liver span 7 cm, nyeri ketok CVA
D
Palpation : Liver and spleen are not palpable, pain on
palpation CVA D - -
Extremities: Warm ; oedema - -
 COMPLETE
Parameter Hasil
BLOOD COUNT Nilai
Satuan Rujukan
(6 DEC 2017)
Ket.

WBC 8.34 10µ/µL 4.1 - 11.0

Neu 7.48 89.63% 10µ/µL 2.50 - 7.50 47 - 80 H

Lym 0.48 5.69% 10µ/µL 1.00 - 4.00 13 - 40 L

Ba 0.02 0.25% 10µ/µL 0.0 - 0.1 0.0 - 2.0

Eo 0.03 0.34% 10µ/µL 0.00 - 0.50 0.0 - 5.0

Mono 0.34 4.08% 10µ/µL 0.10 - 1.20 2.0 - 11.0

RBC 2.59 106/µL 4.0 - 5.2 L

MCV 98.14 fL 80.0 - 100.0

MCH 29.08 Pg 26.0 - 34.0

MCHC 29.63 g/dL 31 - 36 L

HGB 7.54 g/dL 12.0 - 16.0 L

 COMPLETE BLOOD COUNT (3 DEC 2017)
Parameter Hasil Satuan Nilai Rujukan Ket.

HCT 25.44 % 36.0 - 46.0 L

PLT 128.40 10µ/µL 150 - 440 L

RDW 13.61 % 11.6 - 14.8

 FAAL HEMOSTATIS (6 DEC 2017)
Parameter Hasil Satuan Nilai Rujukan Ket.
INR 1.27 0.9 - 1.1 H
PPT 15.3 detik 10.8 - 14.4 H
APTT 28.9 detik 24 - 36
 BLOOD CHEMISTRY (6 DEC 2017)
Parameter Hasil Satuan Nilai Rujukan Ket.
SGOT 14.9 U/L 11.00 - 27.00
SGPT 5.00 U/L 11.00 - 34.00 L
Albumin 3.9 g/dL 3.40 - 4.80
Glukosa
Darah 111 mg/dL 70 - 140
(Sewaktu)
BUN 105.5 mg/dL 8.00 - 23.00 H
Creatinin 11.49 mg/dL 0.50 - 0.90 H
 BLOOD GAS ANALYSIS (3 DEC 2017)
Parameter Hasil Satuan Nilai Rujukan Ket.
pH 7.17 7.35 - 7.45 VL-Critical Value
pCO2 37.7 mmHg 35.00 - 45.00

pO2 113.50 mmHg 80.00 - 100.00 H

Natrium 141 mmol/L 136 - 145

Kalium 4.66 mmol/L 3.50 - 5.10

Klorida 95 mmol/L 96 - 108 L

BEecf -15.3 mmol/L -2 - 2 L
HCO3- 13.30 mmol/L 22.00 - 26.00 L
TCO2 14.40 mmol/L 24.00 - 30.00 L
SO2c 97.0 % 95 % - 100 %
IMAGING (CXR, RSUP SANGLAH, 6 DEC 2017)
CONSCLUSION:
- Cardiomegaly,
aortosklerosis
- Skoliosis torakolumbalis
IMAGING (BOF, RSUP SANGLAH, 6 DEC 2017)
CONSCLUSION:
- Tidak tampak batu
radioopaque sepanjang
traktus urinarius
IMAGING (USG UROLOGI, RSUP SANGLAH, 04 MEI 2017)
CONSCLUSION:
- Batu calyx on upper pole kidney S
- Nephritis cronis bilateral
 ECG

• HR 75 bpm
• Axis Normal
• P mitral
• PR int <0.2, QRS <0.12
• SV2+RV5 >35
Cons: susp. LAH and LVH
ECHOCARDIOGRAPHY (3-5-2017)

-LV Concentric Hypertrophy

-Decrease Diastolic function Gr II
-TR Mild
 ASSESSMENT
1. Observasi flank pain susp kolik ureter ec batu ginjal dd batu
ureter
2. CKD stage V ec. PNC
• Acidosis metabolic
• Moderate Anemia NN on CKD
• Hypertension stg II
3. Obs. Cardiomegaly ec. Susp HHD
3. Malnutrisi
 TREATMENT
HD  rejected
Infus NaCl 0.9% 8 tpm
Diet CKD 35 kal/kgBB/day, protein 0.8 gram/day
Amlodipine 10 mg every 24 hours oral
Valsartan 60 mg every 24 hours oral
Asam folat 2 mg every 12 hours oral
Monitoring
 Complaint and vital sign
 Fluid balance

Planning:
- Konsul TS Kardio
- -Konsul Bagian Gizi
THANK YOU