Morning Report

Okt, 15th 2014

1. CKD stage V newly diagnosed
2.Hyperkalemia
3. Hyperphosptemia
4. HT Stage 2
5. Dyspepsia syndrome
6. Anemia N-N
7. hyponatremia hypoosmolar euvolemik
 Summary of Data Base
• Mr. S/ 38 yo/ W.27
• Chief complaint: Nausea and Vomited
(auto and Heteroanamnesa)
• Patient presented with the chief complaint nausea and vomiting since 2
months ago, 3x/day, the vomiting didn’t contain anything. He had loss
appetite since 5 days ago. He ate about 5 – 6 spoons/ ate 2x times/day. he
was admitted at Lawang Hospital twice because this complained. The first
22 September 2014 and the second 4 Oktober 2014. He had diagnosed
renal failure and heart disease because his creatinin 30 mg/dl and Hb 6
mg/dl. He got transfusion 4 pack at lawang hospital. He known he had
hypertension at Lawang hospital which his blood pressure 180/- mmHg.
• History of pass illness:
• He didn’t know he had hypertension
• No DM
• Family History: his father had hypertension and was died
because diabetes mellitus
• Social History: He worked as a labour at ades drink since 1.0
years ago. civil cervant but retired because CVA, has 1 wife
and 2 children, no history of drinking alcohol, no smoker.
 Physical examination
BP = 160/90 mmHg PR = 80 regular strong RR : 20 tpm, Tax : 36,5 °C

General appearance looked moderately ill GCS 456

looked normoweight
Head Pale conjunctiva + Pupil isocor 3 mm/3 mm
Icterus Sclera -
Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -
Chest Heart: Ictus invisible and palpable at ICS V, MCL Sinistra
LHM ≈ ictus,
RHM: SL D
S1, S2 single, murmur (-)
Lung: Symetric, SF D = S N v v Rh - - Wh - - no additional
breath sound v v -- --
v v -- --
Abdomen and Genital Flat,soefl, liver span 8 cm, traube space tympani, shifting dullness (-)
bowel sound (+) normal,
Extremities Oedema -/- dry skin
-/-
 Laboratory finding (Okt, 15th 2014)
Lab Value Lab Value

Leukocyte 9070 3.500-10.000/µL Natrium 129/128 136-145 mmol / L

Haemoglobine 7,9 11,0-16,5 g/dl Kalium 7,71/6,56 3,5-5,0 mmol / L

MCV 80.80 80-97
MCH 27,6 26,5-33,5 Chlorida 109/113 98-106 mmol / L

PCV 23,1 35-50% SGOT 3 0-40U/L

Trombocyte 149.000 100.000- SGPT 7 0-41U/L

390.000/µL
Eu/bas/Neu/Ly/Mo 0,2/0,3/84,8/1/0 RBS 114 <200 mg/dl
,8/3,9
Ureum 411,3 10-50 mg/dL Phospor 9,5 2,7-4,5

Creatinine 30,2 0,7-1,5 mg/dL kalsium 9,2 7,6-11

eGFR 1,74 ml/mnt/1.73m2 Osmolarity 265

URINALYSIS
Result Result
SG 1,025 10 x

PH 5,5 Epithelia 0,3

Leucocyte trace Cylinder -

Nitrite - Hyaline

Protein 3+ Granular

Glucose - Leukocyte

Erythrocyte 1+ Erythrocyte
40 x
Keton urine - Eritrosit 1,7
Urobilinogen - Eumorfik
Bilirubin - dismorfik
Leukocyte 5,8
Bacteria 54,1 x 10 3
jamur
 Laboratory Finding (Okt, 15th 2014)
BGA Value

PH 7.17 7,35-7,45

PCO2 20 35-45

PO2 102,3 80-100

True O2 102,3

HCO3 7,3 21-28

O2 saturation 96,2% > 95%

Base Excess -21,4 -3 until +3

Conclusion Acidosis Metabolic partially compensated alcalosis

respiratoric
 CUE AND CLUE PL IDx PDx PTx PMo
Male/ 38 yo w27 1. CKD stage V 1.1 IgA Renal biopsy Negative fluid balance - Subjective
Diagnosed as CKD,
Hrypertension newly
newly nephropa 500-(-1000 VS
PE: GCS 456 diagnosed thy Renal diet: 1700Kcal/d; Protein esbach
BP 160/90 1.2 GNC Low salt<2gr/d; protein
Conj anemi +, 1.3 PNC 0,6-0,8 gr/KgBW/day
Dry skin +
Lab:
Hemodialysis
Hb 7,9 mg/dl
MCV 80,8 fl
MCH 27,6 pg
Ur/Cr 411,3 mg/dl /30,2mg/dl
eGFR 1,74 ml/mnt/1.73m2
Phospor : 9,5
BGA : metabolic acidosis
partially compensated alcalosis
respiratoric
 CUE AND CLUE PL IDx PDx PTx PMo

Male/ 38 yo w27 2.Hyperkalemia 2.1 CKD Inj Calcium Gluconas VS

Diagnosed as CKD, Stage 5 Inj D40% 2 flsh Complain, se
Hypertension newly Inj insulin short acting 10 post correction,
Nausea iu SC BGA
Vomitting Calisum Polyetsteren
PE: GCS 456 Sach 3x1
BP 160/90
Low potassium diet
RR 20 tpm,
Dry skin +
Lab:
K : 7,71/6,56
Ur/Cr 411,3 mg/dl
/30,2mg/dl
eGFR 1,74 ml/mnt/1.73m2
BGA : metabolic acidosis
partially compensated
alcalosis respiratoric

Male/ 38 yo w27 3. 3.1 dt CKD -CaCO3 2x 500 Subjective

Diagnosed as CKD, Hyperphospt Stage 5
Conj anemi +,
emia
Dry skin +
Lab:
Phospor : 9,5
 CUE AND CLUE PL IDx PDx PTx PMo

Male/ 38 yo w27 4. HT Stage 2 4.1 Primary HT Low sodium salt diet < 2 S, VS
Hypertension newly 4.2 Secondary HT g/day Fundusco
diagnosed Amlodipin 1x10 mg py
BP 160/90
Male/ 38 yo w27 5. Dyspepsia 5.1 Uremic Inj Metoklopramid 3x10 Subjectiv
Hrypertension newly syndrome gastropaty mg e
Nausea and Vomitting since 2
Inj omeprazole 1x 40 mg
month ago
Lab:
Ur/Cr 411,3 mg/dl /30,2mg/dl
eGFR 1,74 ml/mnt/1.73m2

Male/ 38 yo w27 6. Anemia N-N 6.1. def EPO SI, saturation Treat CKD S, VS, Hb
Diagnosed as CKD, 6.2. Chronic transferin Plan for EPO level
Hrypertension newly disease If
PE: GCS 456 Ferritin > 200
BP 160/90 ST >20%
Conj anemi +, Until Hb>11mg/dl
Dry skin +
Lab:
Hb 7,9 mg/dl
MCV 80,8 fl
MCH 27,6 pg
Ur/Cr 411,3 mg/dl
/30,2mg/dl
eGFR 1,74
ml/mnt/1.73m2
Phospor : 9,5
 CUE AND CLUE PL IDx PDx PTx PMo

Male/ 38 yo w27 7. hyponatremia 8.1 Renal loss UNa Treat underlying disease SE/3 day
Dry skin hypoosmolar 8.2
Lab: euvolemik
Na : 129
Osmolarity : 265
Thank you