SUMMARY OF DATA BASE

Male/ 41yo/W.25
Chief complain : shortness of breath
Patient suffered from shortness of breath since 5 days before admission and worsen since
1 day ago. Patient felt shortness of breath if did activity or walking for 100 meters or more.
Patient slept need 3-5 pillows and cough at night since 1 month ago.
Patient complained about leg swelling since 5 days ago and that condition make him
didn’t to walked. Patient felt fever since 1 month ago, gradually onset, and sometimes he felt
chill with cold sweating
He also complained about nausea and vomiting, bloating sensation since 1 month ago.
Doctor diagnosed him with renal failure since 2 years ago but he was refused to HD.
His passing stool normal, urine production after renal failure was decreased. The patient
often passing urine but a little amount. Patient had diabetes mellitus since 7 years ago but
not routine control and he had hypertension since 5 years ago and did not routinelly
controlled. High blood pressure 180/100 mmHg
• History of pass illness
- History high blood sugar with value 600
mg/dl. History consumed Oral anti diabetic
like glibenclamid, amaryl, metformin.
- history hospitalized 2 years ago dt renal
failure.
- history chronic cough because lung TB and
routin consumed OAT
• Social history
Smoked since 20 years ago 2 pack per day
Married and have 3 childrean
 Physical examination
BP = 150/90 mmHg PR = 100 bpm, RR =26 tpm,SpO2 Tax : 37,4 °C
regular strong 99% with NRBM 10
lpm
General appearance looked moderately ill, O2 GCS 456 , looked overweight
NRBM attached 10 lpm, looked dyspneu
Head Pale conjunctiva + Pupil isocor 3 mm/3 mm,
Icterus Sclera -

Neck JVP R + 4 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS VI 2 cm lat MCL Sinistra
LHM ≈ ictus,
RHM: SL D
S1, S2 single, murmur (-), gallop (-)

Lung: Symetric, SF D= S bv bv Rh - - Wh - -
bv bv -- --
bv bv ++ --
Abdomen Flat, Soefl,liver span 8 cm, traube space tympani, bowel sound ( +)
normal, shifting dullness (-)

Extremities Oedema pitting -/+

 Laboratory finding (19-8-2014 /20-8-2014 POST HD)
Lab Value Lab Value
Leukocyte 10.570 3.500- Natrium 124/125/ 136-145 mmol / L
10.000/µL 129
Haemoglobine 9.1 11,0-16,5 g/dl Kalium 6.5/4.92/ 3,5-5,0 mmol / L
MCV 83 80-97 4.45
MCH 25.4 26,5-33,5 Chlorida 103/103/ 98-106 mmol / L
105
PCV 29.7 35-50% RBS 140/72/1 < 200 mg/dL
32
Trombocyte 516000 100.000- SGOT 35 11-41U/L
390.000/µL
Eo/Ba/Neu/Ly/ 12.6/0.7/6 SGPT 42 10-41U/L
Mo 5.6/15.4/5
.7
Ureum 114.7/67. 10-50 mg/dL albumin 2.87 3.5-5.5
8
Creatinine 7.2/4.35 0,7-1,5 mg/dL Osmolarit 256,75
eGFR 8.97 mL/min/1.73
 URINALYSIS
Result Result
SG 1.015 10 x

PH 6 Epithelia 12.5

Leucocyte 1+ Cylinder -

Nitrite - Hyaline -

Protein 2+ Granular -

Glucose - Leukocyte

Erythrocyte 3+ Erythrocyte
40 x
Keton urine - Eritrosit 150.9
eumorfik +
Urobilinogen - Leukocyte 13.5
Bilirubin - Crystal -
Bacteria coccus/stab 96 x 10
 Laboratory Finding
BGA Value

PH 7.37 7,35-7,45

PCO2 22.4 35-45

PO2 288.7 80-100

True O2 61.23

HCO3 13 21-28

O2 saturation 94.8% > 95%

Base Excess -12.5 12.5

Conclusion Metabolic acidosis fully compensated with mild hypoxemia

 ECG

• Sinus Takikardi, Heart rate 100 bpm

• Frontal Axis : normal
• Horizontal Axis : normal
• PR interval : 0.16”
• QRS complex : 0.08”
• QT interval : 0.32”
• T depresi di I,AVL
• Sokolow lyon = S in V1 + R in V5 = 37
LV strain in V5 V6
• Conclusion : sinus tachicardia with HR 100 bpm and ischemia
high lateral and LVH
 CXR August, 15th 2014
• AP position, asymetric, less inspiration
• soft tissue thin, ICS: widening
• Trachea in the middle
• Hemidiaphragma D/S domeshape
• Sinus costophrenicus D/S: sharp
• Pulmo D/S: increased of BVP, cotton wool appearance
• Cor : site normal, shape normal, size CTR 60 %
• Conclusion : cardiomegaly, lung oedema
 CUE AND CLUE PL IDx PDx PTx PMo
Male/41 yo w.25 1. Post 1.1. Uremic NT-pro O2 10 lpm NRBM VS
A
Shortness of breath ALO Lung BNP Semifowler position Compla
Body swelling, 1.2 HF St C Fluid balance negative 500 in Fluid
decrease appetite Fc IV cc/day balance
PE
GCS 456 Drip furosemid
BP 150/90, PR 100, 10mg/hour at ER and
RR 26tpm, T ax 37.3 C substitute with Inj.
Conj anemi +, JVP = R + 4 cmH20
Cor: ictus ICS VI 2cm MCL S Furosemid 40-40-40 mg
Pulmo : Rh in basal area of lung (iv) on Ward
Edema + HD cito
Dry skin +
Cxr: : heart enlargment, lung
oedem
Lab:
Hb 9.1, MCV 83 MCH 25.4
Ur/Cr 114.7/7.2
Na/K/CL 124/6.5/103
eGFR 8.97ml/mnt/1.73m2
BGA : metabolic acidosis fully
compensated with mild
hypoxemia
 CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 2. CKD 2.1 Kidney O2 10 lpm NRBM VS

A
Shortness of breath St V on Glomerulonefrit biopsy, Renal diet: 1900Kcal/d; Low Compla
Body swelling, HD is Cronis Abdomin salt<2gr/d; protein 0.6-0.8 in
decrease appetite 2.2 DM al USG gr/KgBW/day Fluid
nausea
PE nephropaty Semifowler position balance,
GCS 456 Fluid balance negative 500 Uremic
BP 150/90, PR 100, cc/day sympto
RR 26tpm, T ax 37.3 C
Conj anemi +, JVP = R + 4 Inj. Furosemid 40-40-40 mg ms
cmH20 (iv)
Cor: ictus ICS VI 2cm MCL S Peroral : omeprazole 2x20mg
Pulmo : Rh in basal area of
lung HD cito
Edema +
Dry skin +
Cxr: : heart enlargment, lung
oedem
Lab:
Hb 9.1, MCV 83 MCH 25.4
Ur/Cr 114.7/7.2
Na/K/CL 124/6.5/103
eGFR 8.97ml/mnt/1.73m2
BGA : metabolic acidosis fully
compensated with mild
hypoxemia
 CUE AND CLUE PL
PL IDx
IDx PDx PTx PMo

Male/41
•Male/43 yo w.25
yo 3. HF
Shock
St 3.1
3.1Dilatated Echocardi
Blood Fluid balance
-Drip Dopamine
negative 500 VS
MAP
A
Decrease of
Shortness of breath condition
C Fc IV cardiomyopathy
Cardiogenic culture n
ography, 5-15µg/kgBB/mnt
cc/day UOP
Compl
consciousness
Body swelling, decrease 3.2
shock
Hipertensiv sensitivity
Lipid -Inj. 10
O2 Ceftriaxon
lpm NRBM2x1gr (iv) Extre
ain
appetite,
Cough, whitish sputum Heart Disease test
profile -Inj. Ciprofloxacin
Semifowler position
2x200mg (iv) mties
Fluid
PND
and lowdegrade
Despneu Effort fever 2 3.3
3.2CAD
Septic Confirm diagnosis for lung TB CRT
balanc
weeks
smoking shock Sputum eBGA
PE
PE: GCS 115 3.2.1 lung culture n SaO2
GCS 456
BP 90/50PR 100,
BP 150/90, infection sensitivity
PR 50 bpm
RR 26tpm, T ax 37.3 C 3.2.2 test
Conj anemi
RR 32tpm, +, JVP =R+4
cusmaull Pneumonia
cmH20
Pulmo
Cor: ictus: ICS
RhVIin2cmall MCL
areaS CAP AFB
of lung
Pulmo : RhS in basal area of 3.2.2 Lung TB
lung
Diminish vesicular with
Edema +
sound
Dry skin in+ middle and secondary
basal areaenlargment,
Cxr: : heart of lung Dlung infection
Lab:
oedem
Lab:
Leuco
Hb 9.1, MCV 800083 MCH 25.4
Mono30.5%
Ur/Cr 114.7/7.2
Na/K/CL
PORT score 124/6.5/103
203
eGFR 8.97ml/mnt/1.73m2
BGA : metabolic acidosis fully
compensated with mild
hypoxemia
 CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 4. HT St 4.1 Secondary Fundusco •Low salt diet <2 gr/day BP
A
Hypertension since 5 years I HT py •PO: Clonidine 3x 0,15mg SE/3
ago 4.1.1 Valsartan 80 mg 1x1 day
smoking Renoparenchym
PE:
GCS456 al HT
GCS 456 4.2 Primary HT
BP 150/90, PR 100,
RR 26tpm,

CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 5. DM TII HbA1C,FB Diet DM 1900kcal/day FBG,
A
DM since 7 years ago
G, 2HPPB
Poorly controllled 2HPPBG G
Not routinly took
glibenclamid, amaryl,
metformin
Past RBS 600
Lab:
140/72/132
 CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 6. 6.1 Renal loss Diet protein 1-1.2/kgbb/day Alb

A
Body swelling, decrease Hypoalb 6.2 Low intake
PE uminemi
Edema + a
Dry skin +
Lab
Albumin : 2.87
Proteinuria 2+

CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 7. 7.1 dilutional Inj. Furosemid 40-40-40 mg (iv) VS

A
Shortness of breath Hyponat Fluid balance negative 500 Compl
PE remia cc/day ain
GCS 456 Hypoao Fluid
BP 150/90, PR 100,
RR 26tpm, T ax 37.3 C molare balanc
Lab : Hypervo e
Na : 124 lemik
Male/41 yo w.25 8. UTI 8.1 urethritis Cultur Inf. Ciprofloxacin 2x200mg UL
A
Febris 8.2 Cystitis Urine
Polyuria
PE
GCS 456
BP 150/90, PR 100,
RR 26tpm, T ax 37.3 C
Lab:
Urinalysa
Leucocyte :13,5
Erytrocyte : 150,9
Eumorfik +

CUE AND CLUE PL IDx PDx PTx PMo

Male/41 yo w.25 9. 9.1. Def EPO dt Renal DM diet: 1900Kcal/d; Subj

Lab :
Hb 9.1, MCV 83 MCH 26.4 Anemia CKD st V SI,IBC, Low salt<2gr/d; protein 0.6-0.8 CBC
NN 9.2 Chronic Ferritn gr/KgBW/day
disease serum
Problem analysis

Hypertension Long standing DM

HF ST C FC IV CKD ST V Anemia NN

hyponatremia
ALO
 Risk Factor analysis, CKD
• 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 +
 Risk Factor analysis HF
• Hypertension
• Coronary artery disease
• Heart attack
• Irreguler heartbeats
• Diabetes
• Some diabetes medication
• Congenital heart defects
• Viruses
• Aclohol use
• Kidney condition
 Management analysis
•Bed rest
•Semifowler position
•Diet DM Renal diet: 1700Kcal/d; Low
salt<2gr/d; protein 0.6-0.8 gr/KgBW/day
•Negative fluid balance 500cc/day
•Iv plug
•Inj furosemide 40 mg-40mg- 40mg IV
•Inf ciprofloxacin 2x200mg IV
•PO: Clonidine 3x 0,15mg
 Condition this morning
• BP: 150/100 mmHg
• PR: 76 bpm
• RR: 32 tpm
• Tax: 37,3 Celcius
Thank You