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