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Morning ReportFebruary, 14th 2016
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Summary of Data BaseAnamnesis :
Mrs. Suiati!4" yo! #. 26
• $hief %omp&aint : Shortness of breath 'atient su(ere) from shortness of breath sin%e si* month ago,
intermittent&y but +orsening in the &ast t+o )ays beforea)mission. n the &ast t+o )ays shortness of breath o%%urre) +hen
she )i) hea-y nor mi&) a%ti-ity su%h as +a& to the bathroom.Shortness of breath some+hat re&ie-e) by rest but in the &ast t+o)ays )i)nt re&ie-e) e-en she too a rest. She a&so s&ept on /pi&&o+s an) in the ha&f sitting position. She a&so often +oe up inthe night be%ause of shortness of breath.
She a&so su(ere) from nausea +ithout -omiting sin%e one+ee ago, be%ause of this %on)ition she a&so su(ere) from)e%rease of appetite, she on&y ate " 6 spoon of ri%e an) herfami&y reporte) that her bo)y +eight &ooe) sinny.
She a&so %omp&ain about %ough sin%e t+o )ays ago +ith
+hitish sputum espe%ia&&y in the morning sin%e she su(ere) fromshortness of breath, an) )i)nt a%%ompanie) +ith &o+ gra)e fe-er
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She often %onsume) the tra)itiona& poison if she fe&t pain after she +ore).She use) to )o it sin%e she +as young.
She +as )iagnose) en) stage rena& fai&ure sin%e si* months ago, an) got
routine&y haemo)ya&isa t+o times per +ee e-ery Mon)ay an) hurs)ay, the&ast s%he)u&e of haemo)ya&isa about four )ays ago.
She a&so )iagnose) +ith hypertension sin%e one year ago, at that time theb&oo) pressure +as 200!...but she )i)nt routine&y %ontro&&e)
She a&so %omp&aint her passing urine +as )e%rease) sin%e she )iagnose)+ith en) stage rena& )isease, an) the -o&ume per )ay about 100 200 %%. 3o
history of )iabetes me&&itus
'ast me)i%a& history :
n the &ast si* months she hospita&ie) more than eight times at RSS5 be%auseof shortness of breath
Fami&y istory :
er mother su(ere) from hypertensionSo%ia& istory :
She is a pensioner, marrie), she has t+o %hi&)ren.
5&&ergi% history :
She )oesnt ha-e foo) an) )rug a&&ergi%
Me)i%ation istory :
She routine&y %onsume) irbesartan, furosemi)e, is)n, am&o)ipine, a& 7+henshe un)er+ent the hemo)ya&ie8
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General appearance looked severely ill GCS : 456
BP= 234/140 mmHg(ER) 210/80 mmHg
(ward)
PR = 120 bpm (ER) 89bpm regular strog
(ward)
RR = 40 tpm(ER) 28 tpm
(ward)
!a" # 3$%$ 0&
Head Conjunctiva Anemic (+ !cteric ("
#eck $%& ' + 4 cm H) *)position
,ora- Heart !ctus invisi.le / palpa.le at cm lat !CS %! 0C1 S'H0 : S1 21H0 : ictus cordisS3 S sinle mur mur (reular alllop ("
1un Simetric S7 2 8 S s s v v ', + + (9' ', " "
s s .v .v ' ' + + s s .v .v ' ' + +
A.domen Soel ;S + # liver span < cm= Spleen impalpa.le trou.e spacetympani s,itin dullness ("
9-tremities &ittin 9dema " >" Acral : ?arm and dry +>+
'9S$5 ;
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ab >a&ue73orma&8
ab >a&ue 73orma&8
euo%yte 12??0 4.@00 11./00 !A 3atrium 1// 1/614"mmo&!
aemog&obine
@,20 11,4 1",1g!)&
Ca&ium 4.2? /,"",0 mmo&!
RB$ 2,4 4.0 ".0106!A
$h&ori)a 10@ ?106 mmo&!
rombo%yte 260.000 142.000 424.000 !A
Ereum ?4,20 2040 mg!)
$reatinine ?,/@ 1,2 mg!)
aemato%rit
22,/0 G / 42 G eHFR6
m&!min!1.@2m2
M$> ?0.@0 0?/ I HDS 2@1 200M$
2?./02@/1 pg $a&sium
.@@.611.00mg!)
;o!Bas!3eu!&imf!Mon
0,"!0.2!1,0!1",!2,
"
04!01!"16@!2"//!2
"
=sm2@?
20 2?"mosm!g
SH= 2? 0/2 mE!) 5&bumin 4,26 /.""." g!)
5B=R5=R9 F3D3H 7140220168
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BH5 +ith =2 10 &pm 3RBM 714!02!20168
>a&ue 3orma& >a&ue
' @./6 7.35-7.45
'$=2 2?,@ 35 – 45 mmHg
'=2
26/,0 80 – 100 mmHg
$=/ 1@,6 21 – 28 m mol/L
=2 sat 5rt ?@,@ G > 95 %
B; @,@ (-3) - (+3) m mol/L
b 6,?
rue =2 "",/? mmg 80 – 100 mmHg
$on%&usion : a%i)osis metabo&i% fu&&y %ompensate) +ithmo)erate hypo*emia
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5B >5E; 5B >5E;
urbi)ity $&ear 10 *$o&our 9e&&o+ ;pithe&ia ",2
' 6,0 $y&in)er 3egati-e
SH 102" ya&ine
H&u%ose 3egati-e Hranu&ar
'rotein /J
Ceton 3egati-e 40 *
Bi&irubin 3egati-e ;rythro%yte /,1Erobi&inogen 3egati-e euo%yte 6,@
3itrite 3egati-e $rysta&
eu%o%yte 3egati-e Ba%teria "01,/ * 10
B&oo) 2J =thers
URINALYSIS February 14th 2016
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;$H
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$
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$E; 53D $E; ' )* 'D* '* 'Mo 'e)u
Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort
'aro*ysma& 3o%turna&Dyspneu=rthopneu3auseaDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al
e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpmDry sin J5nemia $onun%ti-a
K>' L R J 4 %m207/08
$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JE=' "00 %%!12 hourLab %n!in&sb @,/ gr!)
Er!$r ?4,20!?,/@mg!)&
1.Shortness ofbreath
1.1 5%ute ung=e)ema
1.1.15%%e&erate)
hypertension
1.1.2 eartFai&ureStage $ F%>
1.1./ =-er&oa)syn)rome
;%ho%ar)iography
=2 10 &pm -ia 3RBMSemifo+&er positionBe) restn Furosemi)e 0 mg
> %ontinue +ithFurosemi)e )rip 20mg!hourDrip 3i%ar)ipine " 1" mg!hour unti& M5')e%rease 2" G7target 1@"!10"mmg8
3egati-e Iui)ba&an%e "00 %% per)ayemo)ia&ysis $ito
>S$omp&ainErine
pro)u%tion
F&ui)restri%tion,e*p&a
nationaboutrena&rep&a%ementthera
py
8/19/2019 Morning report CKD
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$E; 53D $E; ' )* 'D* '* 'Mo 'e)u
Female/45 yo/ar!26AnamnesisShortness of breath3ausea
Diagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#ale$aminationH$S 4"6B' 210!0 mmg'R ? bpm
RR 2 tpm K>' L R J 4 %m207/08$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eLab %n!in&sEr!$r ?4,20!?,/@
mg!)&eHFR 6m&!mnt!1.@/m2
2.ypertension;mergen
%y
2.1 ;ssentia&7primary8
2.2 Se%on)ary2.2.1
Renoparen%hyma&
2.2.2Reno-as%u&ar
=2 10 &pm -ia 3RBMSemifo+&er positionBe) restDrip 3i%ar)ipine "
1" mg!hour unti& M5')e%rease 2" G7+ithin 1 hour87target 1@"!10"mmg8'er ora& :rbesartan 00/00mg tab&et$&oni)in / * 0,1" mgtab&et
>S7b&oo)press
ure,M5'8$omp&ain
Disease,%omp&i%ati
on,targettreatment
8/19/2019 Morning report CKD
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$E; 53D $E; ' D* 'D* '* 'mo 'e)u
Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort'aro*ysma& 3o%turna&Dyspneu=rthopneuDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpm5nemia $onun%ti-a
K>' L R J 4 %m207/08$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JLab %n!in&sb @,/ gr!)Er!$r ?4,20!?,/@ mg!)&eHFR 6 m&!mnt!1.@/m2$entri%u&ar
/. eartFai&urestage $F$ >
/.1 ypertensi-eheart)isease
/.2 uremi%
%ar)iomyopathy
;%ho%ar)iography
=2 10 &pm 3RBMBe) rest3egati-e Iui) ba&an%e"00 %%!)ay
Semifo+&er positionFurosemi)e 7as abo-e8
>SSubF&ui)ba&an%e
Disease,treatment,
prognosa
$E; 53D $E; ' D 'D ' ' '
8/19/2019 Morning report CKD
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$E; 53D $E; ' D* 'D* '* 'mo 'e)u
Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort
'aro*ysma& 3o%turna&Dyspneu=rthopneu3auseaDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al
e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpmDry sin J5nemia $onun%ti-a
K>' L R J 4 %m207/08
$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JE=' "00 %%!12 hrLab %n!in&sb @,/ gr!)
Er!$r ?4,20!?,/@mg!)&eHFR 6
4.$hroni%Ci)neyDisease
stage "=nRoutineemo)ya&isis
4.1 3ephros%&erosis
4.2 3S5D
3ephropathy
=2 10 &pm -ia 3RBMSemifo+&er positionBe) rest3egati-e Iui) ba&an%e
"00 %%- p&ugRena& Diet 1?00%a&!)ay o+ sa&t 2g!)ay, 'rotein "0g!)ayFurosemi)e )rip 20mg!hour
'er =ra& :$&oni)ine / * 0,1" mgrbesartan 00/00 mg
emo)ia&ysis $ito
>S$omp&ainErine
pro)u%tionEreum$reatinin
F&ui)restri%tion,e*p&a
nationaboutrena&rep&a%ementthera
py
$E; 53D $E; ' D 'D ' 'M ' )
8/19/2019 Morning report CKD
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$E; 53D $E; ' D* 'D* '* 'Mo ' e)uFemale/45 yo/ar!26AnamnesisShortness of breathDiagnose) as i)neyfai&ure"hysi#al
e$aminationH$S 4"65nemia $onun%ti-aLab %n!in&sb @,/ gr!)M$> ?0,@0 IM$ 2?,/0 pg
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erytropoetin
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RBS : 2@1 mg!)
6.
yperg&y%emia state
6.1 Stress
n)u%eyperg&i%emi%State
6.2Diabetes
Me&&itustype 2
Fasting
B&oo)H&u%ose2 our 'ost'an)ria&B&oo)H&u%ose
$onrm the
)iagnose) 7+aitfor the FBH an)2''BH8
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on,treatment
Female/45 yo/ar!26AnamnesisShortness of breath"hysi#ale$aminationRhoni J!J;)ema J!J3atrium : 1// mmo&!
@.yponatremiahipoosmo&arhyper-o&emi%
@.1 >o&umeo-er&oa)
BK '&asma;&e%tro&yteurine
Furosemi)e asabo-e
S;post%orre%tion
Disease,treatment,%omp&i%ation
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