MORNING REPORTDr. Zainudin

Monday, 2nd Sept 2013

PHYSICIAN IN CHARGE:

I A : dr. Zainudin, dr DianI B : dr.Deddy , dr. Dian II : dr. Sigit Triyus III : dr. Sri Sunarti, Sp.PD

Moderator : dr. Atma Gunawan, Sp.PD-KGH

SUMMARY OF DATA BASEMale / 51 yo/W. Chief complaint : Shortness of breath (heteroanamnesis)

Patient complained shortness of breath since 3 days ago, even tough he is on rest position. he felt it when she walked to bathroom, he sleep with 3 pillows, and often awake at night due to shortness of breath.he also had cough since 2 days ago, with whitish sputum, sometimes accompanied with fever.

Patient had history of intermitten shortness of breath, usually came up in the morning and relieve by itself.

Patient suffered from leg swelling. Intermittenly. Sometimes followed by pain in his ankle and patient couldn’t walk.

Past Medical History :Patient had history of hypertension since 4 month ago.Patient ever been admitted to hospital because of “usus buntu”, “tipes”,

“infeksi lambung”Patient routinely controlled to pulmonology outpatient department since 4

month ago necause of shortness of breath and got theraphy captopril 3x12.5mg, bisoprolol 1x5mg, diltiazem 2x1tab.

Patient ever been performed endoscopy and the result was gastritis erosiva Family History : There is no family member with hypertension and diabetes mellitus

Social History :Patient used to work at matches factory, had 1 son, and 8 siblings.

SUMMARY OF DATA BASE

General appearance looked severelly illGCS 113 (on midazolam)

BW 70 kg Height 170 cm BMI 24,22 kg/m2

BP=180/80mmHg

PR = 88 bpm irregular, strong RR = 24 tpm, tachypneu Tax :36,5 0C

Head Conjuctiva Anemic (+)Sclera Icteric (-)

Pupil isocor (+) 3/3 mm

Neck JVP R + 2 cm H20, 300 position Lnn. Enlargement (-)

Thorax Cor

Ictus invisible & palpable at ICS VI AAL S,RHM ~SL D, LHM ~ ichtusS1 S2 single regular, murmur (–)

Pulmo Symetric Stem fremitus D=S Sonor + + v v Rh + + Wh - -

+ + v v

+ + - -

+ + v v + + - -

Abdomen Flat , Bowel Sound + N, liver span 10 cm. troube space dullness, Shifting dullness -, turgor +

Extremities Edema - - anemic - - Warm acral + + + + - - + +

PHYSICAL EXAMINATION

LABORATORY FINDINGSLab Value Lab Value

Leucocyte 24.000 4000-11.000/µL Na 136-145mmol/l

Diff Tell 0-4/0-1/51-67/25-33/2-5 %

K 3,5-5,0 mmol/l

Haemoglobin 6.04 11-16,5 g/dL Cl 98-106 mmol/l

MCV 100 80-93 fl Ca 7,6 - 11 mg/dl

MCH 25 27-31pg P 2,7 – 4,7 mg/dl

PCV 40-47 %

Thrombocyte 150-450x103/µL Ureum 16,6-48,5 mg/dL

SGOT/AST 11-41U/L Creatinin < 1,2 mg/dL

SGPT/ALT 11-41U/L GFR ml/min

Alb 3.5-5.5 g/dL RBS < 200 mg/dL

BJ plasma 1,025-1,029 w/v

URINALISISLab Value Lab Value

Cloudy Cloudy Clear 10 x

Color Yellow Yellow Epitel 3,2 ≤ 1lpf

pH 6,0 4,5 - 8,0 Cilinder - Lpf

BJ 1,020 1,010 – 1,015 Hialin - ≤ 2

Glucose Trace Negative Granular - Negative

Protein +3 Negative 40 x

Keton Trace Negative Erythrocyte 26,6 ≤ 3 hpf

Bilirubin - Negative Dysmorfic 66% Hpf

Urobilinogen - Negative Eumorfic 34& Hpf

Nitrit - Negative Leucocyte 68,2 ≤ 5 hpf

Leucocyte +2 Negative Cristal - hpf

Blood + 3 Negative Bacteria 21.252 x 103 ≤ 23 x 103/mL

BLOOD GAS ANALYSIS (17.14 18.36)

BGA Value(with 10 lpm O2)

Normal Value

PH 7,09 7,47 7,35-7,45

PCO2 29,9 28,4 35-45 mmHg

PO2True oksigen

165.8 143,839.5

80-100 mmHg

HCO3 9.2 20,2 21-28 mmol/L

Base Excess -20.8 -3,7 -3 until +3 mmol/L

O2 saturation 96.5 % 99% > 95%

Conclussion Acidosis Metabolik compensated with respiratoric alkalosis with moderate hypoxemia Alkalosis respiratoric mixed with metabolic acidosis with moderate hypoxemia

ECG (1/9/13)

ECG

Sinus aritmia , Heart rate 105 bpm Frontal Axis : N Horizontal Axis : N PR interval : 0,16” QRS complex : 0,08” QT interval : 0,36”

Conclusion : sinus aritmia with HR 105 bpm,

AP position, asymmetric, KV enough, enough inspiration Soft tissue normal, Bone normal Trachea in the middle Hilus D/S thickening Hemidiaphragm D /S are covered by radioopaque shadow Phrenico cotalis angle D/S are covered by radioopaque shadow Pulmo D/S : BVP increased, chepalisation (+), kerley A line Cor site Normal, CTR 73 %Conclusion : cardiomegaly + lung oedema

Chest X-Ray

CUE AND CLUE PL IDx PDx PTx PMo P Edu

Male/51 yo/w 26Ax : Shortness of breathSwelling in legProdcutive coughHistory of feverCOPD treatment

Px :RR : 24 tpmRonkhi in all area of lung

Lab :Hb : 6,0MCV/MCH 100/25,5Leucocyte 24.000BUN 124,9Cr 16,7UL : protein 3+, leucocyte 2+, Blood 3+, epitel 3.2, eri 26 eumorfic, leucocyte 88, bacteria ++, fungi +

BGA : severe acidosis

1. SOB 1.1 Non Cardiogenic1.1.1Uremic lung1.1.2Acute lung infection1.1.3COPD1.1.4 Anemia

Gram, Culture sputum, and antibiotic sensityvity test

O2 10 lpm NRBM

Bed rest semifowler position

Drip Furosemide 20 mg/hour

Inj. Ciprofloxacin 2x200mg IV

S, VS UOPUr/cr

Condition patient and management Restriction of activities and fluid intake

CUE AND CLUE PL IDx PDx PTx PMo P Edu

Male/51 yo/w 26

GCS 345 113

Shortness of breathSwelling in legProdcutive coughHistory of feverCOPD treatment

Px RR : 24 tpmRonkhi in all area of lung

Lab Leucocyte 24.000UL : protein 3+, leucocyte 2+, Blood 3+, epitel 3.2, eri 26 eumorfic, leucocyte 88, bacteria ++, fungi +

CXR Uremic lung dd acute lung infection

2. DOC 2.1 Septic condition

2.1.1 Acute lung infection

2.1.2 Urinary tract infection

2.2. Midazolam

2.3 uremic enchepalopathy

Sputum gram, culture and antibiotic sensitivity test

Urine culture and antibiotic sensitivity test

O2 8-10 lpm NRBM

Inj. Ciproploxacin 2x200mg IV

HD elective

S, VS UOGCSP

Condition patient and management Restriction of activities and fluid intake

CUE AND CLUE PL IDx PDx PTx PMo P Edu

Female 62 yo w 26 K 6,67

3. Mild Hyperpotasemia

3.1. CKD St 5 Inj Ca gluconas 10 mg iv Bolus D40% 50 mg iv

Bolus short acting insulin 10 iu iv

Po Kayeksalate 3x1 sach

S, VS ECG SE level

Diet low potasium

CUE AND CLUE PL IDx PDx PTx PMo P Edu

Female 62 yo w 26Ax Shortness of breathSwelling in legProdcutive coughHistory of feverCOPD treatment

Px RR : 24 tpmRonkhi in all area of lung

Lab Leucocyte 24.000UL : protein 3+, leucocyte 2+, Blood 3+, epitel 3.2, eri 26 eumorfic, leucocyte 88, bacteria ++, fungi +

USG : chronic parenchymatous renal disease

4. CKD st 5 newly diagnosed

4.1. GNC

4.2 HT nefrosclerosis

4.3. IgA Nephropathy

USG abdomen

Renal diet 1700 kcal/day Low salt diet < 2 g/day low potasium Protein 0.6-0.8 gram/kgBW/day

Drip Furosemide 20 mg/hour

Plan for Hemodialysis

S, VS UOPUr/cr

Condition patient and management Restriction of activities and fluid intake

CUE AND CLUE PL IDx PDx PTx PMo P Edu

Female 62 yo w 26 Conj anemis Hb 6,01 g/dl MCV 100,50MCH 25,50

6. Anemia Hyperchromic macrocyter

6.1. dt CKD st 5

6.2 def folic acid 6.3. def B12

Blood smear

Transfusion PRC 1 pack/day durante HD until Hb 8 g/dl

Confirm diagnose

S, VS, HB level

Female 62 yo w 26

RR : 24 tpmBGA : metabolic acidosis

6. Severe meatbolic acidosis

6.1. dt CKD st 5

Nabic 100meq in 100cc Nacl 0,9% 10 Dpm

S, VS, BGA

Female 62 yo w 26

BP 180/80

6. Hypertension stage II

6.1. renoparenchymal hypertension6.2 Primary

Po Clonidin 3x0,15mgPo Nifedipin 3x10mg

S, VS, BGA

Problem Analysis

Hypertension

Anemia Hyperchromic

macrocyter

Hyperpotasemia

GNC

CKD st 5

Shortness of breath Uremic lung

Septic condition

UTI

DOC

Acute lung infection

Uremic enchepalopathy

COPD

Risk Factor

CKD st 5 :1. Hypertension

nefrosclerosis

Management AnalysisEmergency : Hypertension emergency :•O2 10 lpm NRBM•Bed rest semifowler position•Low salt diet < 2 g/day •Drip ISDN 1-10 mg/hour until MAP decreased 25 %

•After targeted achieved : •Maintenance ISDN and give •Clonidin 3 x 0,15 mg po•ISDN 3 x 5 mg po

HyperpotasemiaInj Ca gluconas 10 mg iv Bolus D40% 50 mg ivBolus short acting insulin 10 iu iv

Continued with Ca polystyrene sulfonate 2 x 1 sachet (mixed with 30 cc water)

Management Analysis

• UrgencyCKD st 5 on routine HD : HD cyto HF st C fc IV •O2 10 lpm NRBM•Bed resr semifowler position •Drip Furosemide 20 mg/hour

• Non-urgencyTransfusion PRC 1 pack/day durante HD until Hb 8 g/dl Folic acid 1 x 1000 mcg B 12 3 x 1 tab

Condition this morning :

• Subjective : shorthness of breath relieved• BP : 160/90 mmHg • PR : 75 bpm regular • RR : 18 tpm • Tax : 36,5 • Rh +/+• UOP : 200 cc/ 10 hours

THANK YOU