PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue Problem List and Planning War

Initial Diagnosis d
Medical Consultation from Urology department for Emergency Planning Diagnosis: ER
- (-)
management Azotemia and Hyponatremia
Identity:P2 reg/ Mrs. R/ 49 y.o Urgency Planning therapy
Primary survey : 1. Hydronefrosis berat bilateral Urology Departement
1.1 Intrabladder tumor - Pro Percutaneous Nefrostomi
Airway: patent; Breathing: spontaneous, Circulation: warm Bilateral cito with local anestesi,
Secondary survey : Non-Urgency duration 2-3 h
Chief complaint : Flank pain 2. Suspect intrabladder tumor - Correction Hyponatremia with
3. AKI St. 3 dd Acute On CKD NaCl 3 % 500 cc/24 h
• Patient suffered from flank pain since 1 year ago, worsen 3.1 Obstruktif Uropathy - PO VIP Albumin 3x2 tablet
since 3 month ago, intermittently, accompanied with 3.2 HTN
anuria since 2 days ago 4. HT on Treatment Internal Medicine Suggestion
5. DM type II on Insulin - Renal Diet 1800kkal/day, low
• History of hypertension since 15 years ago and routine 6. Hypoalbuminemia moderate sodium <2 gr/day, Protein 0,6-0,8
consume amlodipine 1x 10 mg gr/kgbb/day
- PO Lisinopril 1x10 mg
• History of DM since 6 years ago and got insulin 6.1 related to renal disease
6.2 Hyperkatabolic state - Avoid Nefrotoksic drug
• Patient diagnosed with suspect intrabladder tumor pro 7. Anemia Hipokrom Mikrositter - HD post operation with indication
PNS Bilateral of Anuria
Objective : GA looked moderately ill, GCS 456, BP 130/90 7.1 def. Fe - Problem Hyponatremia
7.2 related to renal Hypoosmolar Hypervolemia
mmHg, PR 86 x/min, RR 20 x/min, Tax 36,7 C, BW : 46 kg, H 8. Hyponatremia Hypoosmolar caused by dilutional condition,
150 cm, BMI 20,4, UOP : 200 cc/48h (0,09 cc/kg/h) Hypervolemia dt Dilutional treat underlying disease, fluid
restriction and Natrium
Positive Finding K/L conjutiva anemia (+), edema facial (+) // - Monitoring Ur/ Cr post operation,
Tho : Rh (-/-) // Abd soefl, BU (+) normal, suprapubic FBG/2PPBG, SE
tenderness (+), CVA pain (+/+) // Ext : edema (-/-)
Patient will be join care by
Laboratory 26/4/21: DL : 9,1/ 10.300/ 541.000 // MCV/MCH Nefrology division
: 72,7/23,6 // Ur/ Cr : 158/11,9 // eGFR : 3,3, BUN/Cr 6,2
(renal) // SE : 114 / 4,72 / 92, Osm : 259// GDS : 84 // Alb :
2,88 // FH : PT 10,2 (11,0) / APTT 37,4 (25,3) // Eclia NR
CXR there was no metastase pulmo
USG abdomen 23/04/2021 hydronefrosis severe bilateral
USG Evaluation at ER