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Morning Report CKD
Morning Report CKD
Anamnesis :
Mrs. Sujiati/45 yo/ W. 26
Chief complaint : Shortness of breath
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
Neck
JVP R + 4 cm H20 30
position
Thorax Heart
Lung
Simetric SF D = S
Icteric (-)
ss v
v Rh + + (ER) Rh - s s bv bv
+ +
+ +
s s bv bv
+ +
+ +
Abdomen
Extremities
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
0-32 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
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
Hb
6,9
True O2
55,39 mmHg
80 100 mmHg
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
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
Echocar
diograp
hy
VS
Comp
lain
Urine
produ
ction
Fluid
restri
ction,
expla
natio
n
about
renal
repla
ceme
nt
thera
py
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
VS
(bloo
d
press
ure,
MAP)
Comp
lain
Disea
se,
comp
licati
on,
targe
t
treat
ment
PL
3. Heart
Failure
stage C
FC IV
IDx
PDx
PTx
Pmo
VS
Subj
Fluid
balance
P
edu
Disea
se,
treat
ment,
progn
osa
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
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
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