Morning Shift Report Friday, 27-9-2013 dr.

Dikara

Physician In Charge: 1A : dr. Dikara, dr. Dian. 1B : dr. Wisnu, dr. I made Daru II : dr. Vidia III : dr. Didi C, Sp.PD Summary of Data Base Male 48 yo/ w.24B Chief complain : decrease of unconsciousness (heteroanamnesis with his children) Patient suffered from decrease of unconsciousness since 1 day before admission when admitted at RS. Lawang for 7 days. Before that, he often look like sleepy and difficult to communicated so patient referred to RSSA for hemodialized. At RS.Pasuruan he had been diagnosed Kidney failure and Hypoglicemia. He diagnosed CKD since 1 month ago, because of diabetes mellitus. He routinely HD once a week for 1 month at RSSA, but because of hospitalized at RS.Pasuruan he didnt perform HD last week He had been diagnosed DM since 10 years ago, not routinely control, sometimes consumed glibenclamide if he felt not well He also complained nausea and sometimes with vomiting since 3 days ago, accompanied also decrease of appetite He also sometimes complained shortness of breath when he walk over 100m, and relived with rest. Some times woke up in the midnight due to shortness of breath, slept with 2 pillows with leg edema since last month History of social living: He is pensioner PNS, have 4 children, he didnt smoke. His father had hypertension, and his mother had DM. Physical Examination
Ward BP = 170/90 mmHg PR = 98 bpm, regular, strong RR = 24 bpm Takypneu GCS 346 Icteric sclera (-) Tax : 36,8C

General appearance looked severe ill Head Neck Chest Heart: Pale conjunctiva (+) JVP R + 3 cmH2O 30 degree

Ictus invisible and palpable at ICS VI 1 cm lat MCL S LHM ictus RHM: SL D S1, S2 single, murmur (-)

Lung:

Symmetric, SF D=S, normal percussion, Rh - - Wh - - - ++ - Soefl, bowel sound (+) normal, liver span 8 cm, traubes space thympani, shifting dullness ( - ) Leg edema +/+ , warm acral

Abdomen Extremities

Laboratory Findings (september 27th 2013)

LAB Hemoglobin MCV MCH Leukocyte Eo/Bas/Neu/Limf /Mon PCV Trombocyte UA VALUE 9.20 85,2 29.60 8.040 2.2/0,1/78,8 /7.5/10.9 26.50 156.000 8.0 NORMAL 11,0-16,5 g/dl 80-96 fl 26,5-33,5 pg 3.500-10.000/L 0-4/0-1/51-67/2533/2-5 35-50% 150.000-390.000/L 3.4-7.0 RBS Ureum Creatinine Natrium Kalium Chlorida eGFR LAB VALUE 159 118.60 6.21 132 3.62 102 NORMAL < 200 mg/dl 10-50 mg/dL 0,7-1,5 mg/dL 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L

BGA September 27th 2013

PH : 7.43 (N: 7.35-7.45) PCO2 : 40.4.5 mmHg (N: 35-45) PO2 : 44.6 mmHg (N: 80-100) HCO3 : 25.4 mmol/L (N: 21-28) O2 Sat Arterial: 81.7% (N > 95) BE: 1.6 mmol/L Conclusion: BGA Vena

CUE AND CLUE Male/ 64 yo/W. 24B A AMS Nausea Vomiting After HD Diagnosed CKD since 1 month ago Routine HD once/weeks PE TD: 170/90 N: 98 strong RR: 24 takypenu T: 36,9 Lab: RBS stik: High2386106

PL 1. AMS

IDx 1.1 Hyperglicemia in critical ill 1.2 Uremic enchephalopa thy

PDx BGA, SE,

PTx O2 2-4 LPM NC At ward: Inj. Short acting insulin 10 iu iv RBS 1 hour again RBS: 23inj. D40 2 flash iv86IVFD D10% 10 dpm106 Inserted NGTliqui diet 6x200cc

PMo

PEd

RBS/h Therapy

Male/ 64 yo/W. 24B A Diagnosed CKD since 1 month ago Route HD once a week Nausea Vomiting PE: TD: 170/90 PR: 98 RR: 24 takypneu Edem (+/+) Lab: Hb: 9.2 Ur; 118.60 Cr: 6.21 Ua: 8.0 Prod. Urine: Male/ 64 yo/W. 24B A: Diagnosed CKD on HD since 1 month ago History of DM since 10 years ago History of HT uncontrolled since 1 month ago

2.CKD st 5 on HD

2.1 DM nefropathy 2.2 HT Nefroslerosis

USG Abdon eb

O2 2-4 LPM NC Bed rest Fluid balance negative 250cc/d Diet DM 1700kcal/d Low salt <2gr/f Protein 50gr/d Inj. Fursemide 40-0-0mg Inj. Metoclopramide 3x10 mg (prn) HD elective

Prod Therapy, urine, HD S, VS, Ur, Cr

3. HF ST C FC II

3.1 DM cardiomyopat hy 3.2 HHD 3.3 Uremic cardiomyopat hy

Echoca rdiogra phy

O2 2-4 LPM NRBM Semifowler potition fluid balance negative 250cc/24h Lowsalt <2gr/d Inj. Furosemide as above

S, VS, Avoid Urine heavy produ activity ction

PE TD: 170/90 N: 98 strong RR: 24 Ictus palpable at ICS VI 1 cm lat MCL S (LVH) Lower extremitas edem (+/+) Prod urine: Male/ 64 yo/W. 24B A: Hypertension since performed HD uncontrolled Diagnosed CKD since 1month ago PE: TD: 170/90 Male/ 64 yo/W. 24B A: Diagnosed CKD since 1 month PE: Pale conjungtiva (+) Lab: Hb: 9.20 MCV: 85.20 4 HT ST II 4.1 secondary dt rhenoparench ymal HT Primary 4.2 Primary Fundus copy Low salt diet <2 gr/d PO: Amlodipin 1x10mg Clonidin 3x0.15 mg S, BP Therapy and diet

5. Anemia NN

5.1 Chronic disease dt no 5.1 def EPO

Reticul osit count

Treat underlying disease

S, VS , CBC

MCH: 29,6
Male/ 64 yo/W. 24B A: Diagnosed DM since 10 years go Lab: RBS: High2386106 6. DM type II overweigt poorly controlled FBG, 2HPPB G Confirmed diagnosed FBG, 2HPP BG therapy