Dr.

Norma - IPD

MORNING REPORT
Monday, October 31th 2016

PHYSICIAN IN CHARGE:
Jaga I : dr. Nadina, dr. Norma, dr. Dedy (kardio)
Jaga II CVCU : dr. Rina
HCU : dr. Reza
ER : dr. Somarnam, dr. Bastian
Jaga III : dr. Sri Sunarti., SpPD-KGer
Fasilitator : dr. Djoko Heri., SpPD-KHOM
 SUMMARY OF DATA BASE
Female/45 yo/W.28

Chief complaint : Shortness of Breath

Present illness :
Patient was come to ER due to shortness of breath since 1 day before admission. The
SOB was triggered by cough which getting worsen 1 day before admission. Sputum
was greenish in color, did not accompanied with blood. Since 1 week before
admission, the cough was unproductive, and seldom appears. This complain was
accompanied with chills sensation, without increasing body temperature.
Patient was diagnosed with chronic kidney disease since 2 months before admission.
Patient got double lumen insertion not long after diagnosed. Hemodialysis was
performed 1 time per week on Friday.
Patient was diagnosed with hypertension since 2 months ago, coincident with her
diagnosed of CKD.
Past medical history :
Patient was diagnosed with Ca cervix 1 year ago. She was endure a chemotherapy
3 times, then being operated, and then the therapy of Ca cervix was stopped.
 SUMMARY OF DATA BASE
Medication History :
Patient took routinely hemapo, amlodipine 1x5 mg, , clonidine
3x0.15, hemapo. Lisocal (kalsium laktat).

Social History :
Patient was married, did not work. Stay at home as a housewife.
Have 2 child.

Family History :
No history hypertension, Diabetes, nor malignancies in her family.

Review of system :
Patient did not urinate since 2 months ago, since the patient
diagnosed with CKD.
Non pitting Leg edema since 1 weeks ago.
 PHYSICAL EXAMINATION
General appearance : looked moderately ill GCS 456

BP : 150/100 PR : 88 bpm RR : 22 tpm Tax : 36.7 0C

mmHg VAS : 5/10
Head Conj.pale (+), icteric sclera (-), pupil isochore diameter 3 mm.

Neck JVP R+0 cm H2O at 30 degree

Thorax : Cor Ictus invisible and palpable at ICS VI 3 cm lateral of MCL sinistra
LHM ~ ictus RHM: 1 cm SL D
S1, S2 single, murmur (-), gallop (-)

Pulmo Symmetric; SF D=S; S| S V |V Rh -| - Wh - | -

S| S V |V -| - -|-
S| S V |V -| - -|-
Abdomen Rounded, bowel sound normal, soefl, liver span 8 cm, traubes
space tympani. Mass in lower abdomen LLQ, firm margin, 8x6cm
in size, immobile, pain (+).
Extremities Warm acral, pathological reflex (-).
oedema at lower extremity (+)
Lab (30/10/16)
Hematologi Kimia Klinik
Hemoglobin 4.9 13.4-17.7 g/dL ELEKTROLIT SERUM
4.3-10.3 x 103/ 136-145
Leukosit 24,920
mikro L Natrium (Na) 130 mmol/L
Hematokrit 16.6% 40-47 % Kalium (K) 4.68 3.5-5.5 mmol/L
142-424 Klorida (Cl) 102 109 mmol/L
Trombosit 488.000
103/mikroL
MCV 89.7 80-93 fl
MCH 27.4 27-31 pg FAAL HATI
Diff count AST/SGOT 18 0-40 U/L
Eosinofil 0.3 0-4 ALT/SGPT 7 0-41 U/L
Basofil 0.1 0-1 Albumin 3.11 3.5-5.5 g/dL
Neutrofil 78.0 51-67
Limfosit 16.9 25-33
Monosit 4.7 2 s.d 5 FAAL GINJAL
Ureum 105.8 16.6-48.5 mg/dL
Creatinin 8.91 <1.2 mg/dL
11.5 (10.3)/24.2
FH
(25.8)
INR 1.11
Metabolisme Karbohidrat
RBS 165 <200 mg/dL
BGA (30/10/2016)
Value Normal Range
pH 7.38 7.35-7.45
pCO2 29.3 35-45
pO2 100.6 80-100
HCO3 17.4 21-28
BE -8.0 (-3)-(+3)
Sat O2 97.3% >95
Hb 7.00
Metabolic acidosis fully
compensated
ECG (30/10/2016)
ECG (14/03/2016)

Sinus tachycardia, heart rate 140 bpm

Frontal Axis : Normal
Horizontal Axis : Normal
PR interval : 0.16
QRS complex : 0.08
QT interval : 0.28

Conclusion : Sinus tachycardia HR 140 bpm

CXR
(30/10/2016)
CXR (30/10/2016)

AP position, symmetric, high KV, less Inspiration

Trachea in the middle
Soft tissue and bone normal
Hemidiaphragma Scovered by thin
radiopaque shadow ; Ddomeshape
Pulmo : normal
Cor : site N, CTR 75%, ictus upward. Cardic
waist (+)
Conclusion: Cardiomegaly,
 CUE & CLUE PL IDX PDX PTX PMO
Female/45 1. SOB 1.1 Fluid Bed rest Subj,
y.o/W.28 overload Semi fowler BP, HR
SOB since 1 day 1.2 Pneumonia position
before admission 1.3 HF st C FC O2 8-10 lpm
History of IV NRBM
asthma was Plan for HD cito
denied.
SOB was not
relieved with rest
Cough since 1
week before
admission.
Grenish sputum
was out 1 day
before
admission.
Shivering
sometimes,
without any
increased of Tax.

PE:
BP: 150/100
HR: 100 bpm
Rh - - Wh - -
-- --
-- --
 CUE & PL IDX PDX PTX PMO
CLUE
Female/45 2. Anemia 2.1 Renal SI, TIBC, Transfusion Subjective
y.o/W.28 gravis related Ferritin, PRC of PRC 2 Vital sign
Weakness Transferrin pack durante Overload
felt no saturation HD syndrome
energy to do (Hb target 8 Transfusion
some g/dl) reaction
activities Hemapo if
Diagnosed prequirement
as CKD since was
2 months completed,
ago and indicated

PE:
Pale
conjungtiva
(+)

Hb : 4.9
MCV/MCH :
89.7/27.4
Ur/Cr :
105.8/8.91
 CUE & CLUE PL IDX PDX PTX PMO
Female/45 3. CKD st 5 3.1 - Renal diet 1700 VAS, Subj,
y.o/W.28 on routine Obstructiv kcal/day Ur/Cr level/3
Routine HD once a HD e uropathy Low salt days
week, on Friday. 3.2 HT <2g/day Overload
History of Ca nefroscler Low protein 1- syndrome
cervix 1 year ago. osis 1,2 g/day Urine output
Chemo (+) 3 Fluid balance
times, and then negative
being operated 500cc/24hours
No urine Anti
production since 2 hypertension as
months ago. PL no.4
Routine
PE: Hemodialysed
double lumen (+). cito
BP: 150/100
HR: 100 bpm

Lab:
Ur/Cr : 105.8/8.91
BUN : 49.44
eGFR MDRD: 5.11
mL/min/1.73m2
 CUE & CLUE PL IDX PD PTX PMO
X
Female/45 4. HT stage II 2.1 Primary Renal diet 1700 Subj,
y.o/W.28 on Tx HT kcal/day BP, HR
2.2 Low salt <2g/day
hypertention Secondary Low protein 1-1,2
since 2 months Hypertension g/day
ago, when p.o. Valsartan 0-80
diagnosed with mg
CKD. Clonidine 3x0.15
Routine mg
controlled to HD.

PE:
BP: 150/100
HR: 88 bpm
 CUE & CLUE PL IDX PDX PTX PMO
Female/45 5. Pneumonia Sputum Levofloxacin 1x500 Subjectiv
y.o/W.28 CAP culture + mg (Loading) e
Anx : sensitivity 1x250 mg (adjusted Vital sign
SOB was initiated of AB. dose)
by unstopped
cough.
Greenish sputum
Sometimes feel
shivers.
Cough 1 weeks.
No sputum
initially.

PE:
Ictus invisible
and palpable at
ICS VI 3 cm MCL
sinistra
RHM : 1 cm
lateral SL D
Rh - - Wh - -
-- ++
-- --
BP 150/100
HR 88 bpm

CXR:
 CUE & CLUE PL IDX PDX PTX PMO
Female/45 6. HF st 6.1 Uremic Echocardio- Bed rest Subjective
y.o/W.28 C FC IV cardiomyopat graphy Semifowler Vital sign
hy position Urine
Anx : 7.1 HHD Renal diet 1700 productio
DOE (-) kcal/day n
PND (-) Low salt edema
Orthopnea (-) <2g/day
Low protein 1-
PE: 1,2 g/day
Ictus invisible Valsartan 1x80
and palpable at mg
ICS VI 3 cm MCL Clonidine
sinistra 3x0.15
RHM : 1 cm
lateral SL D Negative fluid
balance (250
BP 150/100 cc/24 hours)
HR 88 bpm

ECG:
Sinus
tachycardia.
 CUE & PL IDX PDX PTX PMO
CLUE
Female/45 7. Ca Cervix USG Paracetamol Subjective
y.o/W.28 post Abdomen codein Vital sign
Anx : hysterectom 3x500/20 VAS
Chemo 3 y mg (prn)
times
Surgery 1
year ago
Fluxus (+).
VAS : 5/10

PE:
Abdominal
tenderness
(+).
Mass at LLQ,
8x6 cm in
size.
 Problem Analisis

Heart failure st C Hypoalbuminemia

Hypertension st I
FC IV

Hyperkatabolic state
HT

s
os
Uremic nephrosclerosis Ca Cervix

ll
na
cardiomyopathy renoparenchymal

Re
d Obstructive uropathy
Contact to person
i se Chronic kidney
with chronic cough
rom disease anu
p
m e ria Fluid overload
o t
n oc sta
u
m
Im

Pneumonia CAP Anemia SOB

 CKD Risk Factor

Age > 65 yo
Hypertension
Diabetes Melitus
Heart disease
Smoking
Obesity
Dislipidemia
Consumed traditional potion
Consumed NSAID
Urinary or renal stone
Family history of kidney disease +
 HF Risk Factor analysis

Hypertension
Coronary artery disease
Heart attack
Irreguler heartbeats
Diabetes
Some diabetes medication
Congenital heart defects
Viruses
Aclohol use
Kidney condition
 Hypertension Risk Factor

Age,
race or ethnicity,
Overweight,
Gender (Men > Women),
Lifestyle habits,
a family history of high blood pressure.
 Management Analysis

Hypertension St. II Management of HT st. Low salt diet, <2g/day

II p.o Valsartan 1x80 mg
- Lifestyle modification p.o clonidine 3x0.15
- Two drugs combination mg
of antihypertensive
drugs
Heart Failure Management of Heart This patient received :
Failure - Low salt diet, <2g/day
- Restriction of activity - Injection of
- Dietery sodium Furosemide 2x40 mg
restriction 2-3 gram/ - p.o Valsartan 1x80 mg
day - p.o Clonidine 3x0.15
- Diuretics mg
- ACEIs, ARB
- Hydralazine and Nitrat
- Digoxin
- Anticoagulants
- Inotropic agents
 Management Analysis

Problem Management Fact

CKD - Delaying or halting the Hemodialysis

progression of CKD
- Diagnosing and treating the
pathologic manifestations of CKD
- Timely planning for long-term
renal replacement therapy

Ref : Medscape
Condition this morning

Subj: pain (-), breathlessness (+)

GCS : 456
BP : 130/80 mHg
HR: 90 bpm
RR : 24 tpm
T : 36.4 C
Sat O2 : 99% with NRBM 10 lpm
THANK YOU
Ca Cervix mechanism to be CKD

Kidney failure
Your kidneys remove waste material from your blood. The waste is passed out
of your body in urine through tubes called the ureters. Kidney function can be
monitored by a simple blood test called serum creatinine level.

In some cases of advanced cervical cancer, the cancerous tumour can press
against the ureters, blocking the flow of urine out of the kidneys. The build-up
of urine inside the kidneys is known as hydronephrosisand can cause the
kidneys to become swollen and stretched.
Severe cases of hydronephrosis can cause the kidneys to become scarred,
which can lead to loss of most or all of the kidneys' functions. This is known as
kidney failure.