ckd 28

8/12/2019 CKD 28

1/24

MORNING REPORT

dr.HESTI - IPD

Wednesday, November 27th2013

PHYSICIAN IN CHARGE:

I A : dr. Hesti, dr. Arya, dr. Eldi ( cardio)

I B: dr. Hengki(konsulan), dr. Wisnu ( IGD)

II : dr. Angela Merici

III : dr. Laksmi Sasiarini , SpPD

MODERATOR : dr. BP. Putra Suryana, SpPD-KR

8/12/2019 CKD 28

2/24

Summary of Data Base

Male/ 56 yo/ward 27 move to ward 26

Heteroanamnesa from his son and his brotherChief complain : body swelling

Patient suffered from body swelling since 2 weeks ago, first from his legthen became larger until all of his lower leg and also his scrotum, so hecouldntpassing urine for about 3 days.His stomach getting bigger and he felt

shortness of breath. 3 months before he also complain about shortness ofbreath but it come after he had a hard activity or walked over 200 m. he feltcomfort when slept with 3 pillows, and awake in the night because ofshortness of breath

patient also felt nausea and vomiting since a week ago about 2-3 times@ gelas, contain residualfood. Decreased of apetite since a week ago.

He had been diagnosed hypertency since a year ago, but not routinellycontrolled, blood presure was about 150/mmHg. He also diagnosed asdiabetes mellitus since a year ago and not routinelly controlled too.

8/12/2019 CKD 28

3/24

History of past illness:

21 months ago he felt itchy through out his body, and it cured by itself

and made a rough surface in almost whole body

Family history:

His father died because of liver disease

His brother (number 1 from 10 siblings got hypertension and also DM)

Social and environmental history :

Patient was a bus co-driver and had been married had 4 children

Patient consumed extra joss for about 2 years almost everyday to reduce

his weakness.

8/12/2019 CKD 28

4/24

8/12/2019 CKD 28

5/24

Laboratory finding

Lab Value Lab Value

Leukocyte 14.73 3.500-10.000/L Natrium 131 136-145 mmol /L

Haemoglobine 9.20 11,0-16,5 g/dl Kalium 6.20 3,5-5,0 mmol /L

MCV 86.30 80-97 Chlorida 108 98-106 mmol /L

MCH 28.80 26,5-33,5

PCV 28.50 35-50% SGOT 72 11-41U/L

Trombocyte 209.000 150.000-

390.000/L

SGPT 44 10-41U/L

Eo/Ba/Neu/

Lym/Mo

0.1/0.1/88.

6/6.9/4.3

Albumin 3.11 3.5 5.5

Ureum 193.70 10-50 mg/dL PPT /

kontrol

19.9 /

11.5

Creatinine 8.47 0,7-1,5 mg/dL INR 1.72

eGFR mL/min/1.73 m2 APTT 50.5

GDS 103 < 200 mg/dl kontrol 25.1

8/12/2019 CKD 28

6/24

Laboratory FindingBGA

Supplemented O2 10 lpm

Value normal

PH 7.26 7,35-7,45

PCO2 17.9 35-45

PO2 148.4 80-100

HCO3 12.3 21-28

O2 saturation 98.7 > 95%

Base Excess -19.2 -3 until +3

Conclusion Acidosis metabolic partially compensated

8/12/2019 CKD 28

7/24

8/12/2019 CKD 28

8/24

ECG (November 26th2013)

Sinus tachicardy, Heart rate 115 bpm Frontal Axis : normal

Horizontal Axis : clockwise rotation

PR interval : 0.16

QRS complex : 0.08

QT interval : 0.32

S V1 + R V5/V6 : >35 mm

V1 V2 : OMI

V1 + V4 : PVC

Limb Lead : < 5 mm

Conclusion : Sinus tachicardy With Heart rate 115bpm + LVH + OMI anterior + low voltage

(ALO)

8/12/2019 CKD 28

9/24

CXR (November 26th,2013)

8/12/2019 CKD 28

10/24

CXR (November 26th,2013)

AP position, symmetric, enough KV, less inspiration Soft tissue normal, Bone normal

Trachea in the middle

Hemidiaphragm D is covered with radiopaque shadow, S

domeshape Costophrenicus angle D is blunt, S is sharp

Cor: cardiac waist disappear, size : CTR 67%

Conclusion : Acut lung edema+ Cardiomegaly

8/12/2019 CKD 28

11/24

CUE AND CLUE PL IDx PDx PTx PMo P Ed

Male/56 yo

Ax:

-orthopneu

-PND

-HT since 1 year ago

-had DM since 1 year

ago

PE:

JVP R+5cm H2O

BP : 150/90 mm Hg

Ictus invisible and

palpable at 2 cm lateral

MCL S, ICS VI

Dull at pulmo dextra

Rh +/+ in all area pulmo

CXR: cardiomegaly,

efusi pleura

ECG :

Sinus tachicardy with

HR 115 bpm. With

LVH,with OMI anterior

and low voltage

1. Acute lung

oedem

1.1 non

cardiogenic

1.1.1 CKD

stage V

1.2 cardiogenic

1.2.1 HF stageC

NT pro BNP Bedrest

Semifowler position

Oxygen 8-10 lpm NRBM

Drip Furosemid 20 mg/ hour

Subjective

BP

HR

RR

Urine

productio

n

Bed rest

Fluid

intake

restriction

8/12/2019 CKD 28

12/24

CUE AND CLUE PL IDx PDx PTx PMo P.Ed

Male/ 56 yo :

Ax:

body swelling

Nausea and vomiting

History of DM since 1

years agoHistory of hypertensi

since 1 years ago

PE:

JVP R+5cm H2O

BP : 150/90 mm Hg

Ictus invisible and


MCL S, ICS VIDull at pulmo dextra

Rh +/+ in all area pulmo

CXR: cardiomegaly,

efusi pleura

ECG :


HR 115 bpm. With


and low voltage

2. CKD

stage V

newly

diagnosed

2.1 diabetic

nephropathy

2.2 hypertensi

nephrosclerosis

-abdominal

USG

Kidney diet 1900 kcal/day

protein 1-1,5 gr/kgBW/day, low

salt

8/12/2019 CKD 28

13/24


Male/ 56 yo

-orthopneu

-PND

-HT since 1 year ago

-had DM since 1 year

ago

Hed been diagnosedsince 3 montyh ago

PE:

JVP R+5cm H2O

BP : 150/90 mm Hg

Ictus invisible and


MCL S, ICS VI

Dull at pulmo dextraRh +/+ in all area pulmo

CXR: cardiomegaly,

efusi pleura

ECG :


HR 115 bpm. With


and low voltage

2. HF stage C

cf II

2.1.Hipertency

Heart Disease

2.2.

Congestive

Heart Disease

2.3 Uremic

cardiomyopathy

2.4 Diabetic

cardiomyopath

y

Echocardio

graphy

-.Bed rest + Semifowler position

-.Equal balance fluid

Subjective

BP

HR

RR

Urine

productio

n

Bed rest

Fluid

intake

restriction

8/12/2019 CKD 28

14/24


Male 56 yo

Ax:

-nausea and vommite

since 2 weeks ago

had DM since 1 years

ago

Lab :Ur mg/dl

Cr 5mg/dl

eGFR ml/mnt/1.73

4.Dyspepsia

syndrome

4.1.uremic

gastropathy

4.2. diabetic

gastropathy

4.3 peptic ulcer

disease

Gastric

emtying

test

-Inj.Metochlopramide 3x10 mg Subj, Explain

Manage

ment

Male / 56 yo

Ax :

Had hypertensi since 1

years ago

PE :JVP R + 5 cm H2O

Ictus palpable at 2 cm

lateral SIC VI MCL

sinistra

CXR: cardiomegaly,

efusi pleura

ECG :Sinus tachicardy with

HR 115 bpm. With


and low voltage

5. Hypertency

stage 2

5.1 primary

hypertency

5.2 secondary

hypertensi

(renoparenchimal /

renovascular)

Low salt diet ( < 2gr/day)

Irbesartan 0-300 mg

BP

Lipid

profile

Restrictio

n of salt

CUE AND CLUE PL ID PD PT P P Ed

8/12/2019 CKD 28

15/24

CUE AND CLUE PL IDx PDx PTx Pmo P.Ed

Male/ 56 yo :

Ax:

Had been diagnosed

kidney failure since 3

years ago

Lab :

K : 6,2 6,1

6.

Hiperphosp

atemia

6.1 due to CKD

stage V

Calcium gluconas I ampul

Intravena

Rapid acting insulin 10 IU subcutan

D40% 2 flas bolus

Hemodialisa

Ureum,

Creatini

ne,

BP

HR

RR

SE 4

hours

post

corecti

on

Fluid

restricti

on

8/12/2019 CKD 28

16/24

Condition this morning

Subjective : -

GCS : 456

BP : 130/90mmHg PR : 110 bpm,

RR : 28 tpm

Urine production: 10cc/24 hours

8/12/2019 CKD 28

17/24

L/O/G/O

Thank You!

8/12/2019 CKD 28

18/24

Problem Analysis

CKD

Stage 5

Hypertensio

n

Heart

Failure

stage C cf

IV

Anemia

HT stage 2

Lung

oedema

Dyspepsia

syndrome

8/12/2019 CKD 28

19/24

RISK FACTOR

CKD St V- Hypertension

- Diabetes Mellitus

Heart Failure

-

CKD (uremic

cardiomyopathy)- Hypertension

-

Hypertension

- CKD- retensi Natrium

- activation RAAS

Uremic lung:CKD stage V

Anemia Normochrom -Normositer

-Decrease of EPO

-chronid inflammatory

8/12/2019 CKD 28

20/24

Risk Factors CKD

1. Diabetes

2. Hypertension

3. Heart disease

4. African-Anerican, Native-American or Asian-American race

5. Family history of kidney disease and hypertension

6. Age 65yo7. Hyperuricemia

8/12/2019 CKD 28

21/24

Risk Factors Heart Failure

1. Unmodifiable:

Male

Family history of heart disease, hypertension

2. Modifiable:

Smoking

High LDLUncontrolled hypertension

Physical inactivity

Obesity

Uncontrolled stress/anger

M A l i

8/12/2019 CKD 28

22/24

Management Analysis1. Emergency : -

2. Urgency:

1. Moderate dehidration : Rehidrasi with NaCl 0,9 % 500 cc/in 1 hour

maintenance 16 dpm

2. Azotemia renal :

-Diet 1900 kcalori/day, low salt < 2 gr day, protein 0,6-0,8

mg/kgBW/day.

- equal fluid balance (balance 0)

3. Non-urgency:

1. HF stage c FC II

Bedrest total and semifowler position

Fluid balance 0ISDN 3 x 5 mg

Bisoprolol 1 x2,5 mg

amlodipin 1 x 5 mg

M t A l i

8/12/2019 CKD 28

23/24

Management AnalysisNon Urgency :

2. Hypertensi stage 2

low salt diet < 2gram/ day

Bisoprolol 1x 2,5 mg

amlodipin 1 x 5 mg

3. Dyspepsia syndrome

Injeksi metoclopramide 3 x 10 mg intravena

Injeksi omeprazole 1 x 40 mg intravena

4. DM type 2

Diet DM 1900 kilocalorie/day

postpone oral anti diabetic

8/12/2019 CKD 28

24/24

L/O/G/O

Thank You!

ckd 28

Documents