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Dikara
Physician In Charge: 1A : dr. Dikara, dr. Yanti, dr. Eldi (cardio) 1B : dr. Diana, dr. Lya II : dr. Heri III : dr. Syifa M Sp.PD Summary of Data Base Male 27 yo/ w.25 Chief complain : General weakness (auto and heteroanamnesis with his father) Patient suffered from general weakness since today before go to RSSA for routine HD. Today, at HD room before doing HD blood pressure about 80/40 and he looks very weakness, because the BP decrease he suggested for hospitalized and post poned for HD He also complained shortness of breath when he doing mild activity and some times relived with rest. Some times woke up in the midnight due to shortness of breath, slept with 3 pillows with leg edema since 1 years ago He had ben diagnosed for kindey failure since 2 years ago and routine hemodialized twice per weeks (Wednesday and Saturday) History of hospitalized 3 weeks ago for 15 days, dignosed kidney failure, heart failure and also efusi perikard based on result of echocardiography. He had been discharge 3 days ago got furosemide 40mg, methylprednisolone (3x8mg), irbesartan (1x150mg), Codein (3x10 mg He also complained cough since 1 month ago, sometime with whitish sputum, without fever He also complained nausea and sometimes with vomiting since yesterday accompanied also decrease of appetite Physical Examination
Ward BP = 80/40 (HD) 80/50 (W)mmHg PR = 52 bpm, regular,weak RR = 26 bpm Takypneu GCS 356 Icteric sclera (-) Tax : 37,7C
General appearance looked severe ill Head Neck Chest Heart: Pale conjunctiva (+)
JVP R + 4 cmH2O 30 degree , insterted Double lumen Ictus invisible and palpable at ICS VI 1 cm lat MCL S LHM ictus RHM: SL D, marvel sound (+) 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
AP position, asymmetric, enough KV, enough inspiration Soft tissue and bone: normal Trachea in the middle Sinus phrenicocostalis dextra and sinistra covered by cardiac shadow Hemidiaphragma dextraand sinistra covered by cardiac shadow Lung: difficult to evaluated Cor: site N, shape: neck bottle, size: CTR= more than 70% Conclusion: Cardiomegaly and suggested cardiac tamponade
CUE AND CLUE Male/ 27 yo/W. 25 A General weakness Diagnosed CKD since 2 years ago Routine HD twice/weeks PE GCS 456 TD: 80/50 N: 52 weak RR: 26 takypenu T: 37.7 Lab: Hb: 6.4 Leu: 35.810 Trombo: 200.000 HT: 20.40 RBS: 90
PL 1.Shock Condition
IDx 1.1Cardiogeni c shock 1.1.1 Cardiac tamponade 1.2 Hypovolemic shock 1.2 Septic shock
PTx O2 8-10 LPM NRBM At HD: Rehydration/loading NaCl 0.9% 250cc AT Ward: Drip Dobutamin 220mcg/kgbw/min
PMo
PEd
Male/ 27yo/W. 25 A Diagnosed CKD since 2 yeras ago Route HD twice/week Nausea Vomiting SOB PE: GCS 456 BP: 80/40 PR: 52 RR: 26 takypneu Edem (+/+) Lab: Hb: 6.40 Ur: 263.10 Cr: 8.06 Ua:12.6 Male/27 yo/W. 25 A: Diagnosed CKD on HD since 2 years ago History of HT uncontrolled since HD SOB Dypsneu on effort PND PE GCS 456 BP: 80/40 PR: 52 Weak RR: 24 takypneu Ictus palpable at ICS VI 1 cm lat MCL S Lower extremitas edem (+/+) ECG: sinus tachycardia HR 105 bpm , ischemic inferior, and OMI anterior CXR: Cardiomegaly suggested cardiac tamponade Male/27yo/W. 25 A:
2.CKD st 5 on HD
O2 8-10 LPM NRBM Bed rest Fluid balance negative 0 cc/d durante shock condition Kidney Diet 1700kcal/d Low salt <2gr/f Protein 50gr/d Inj. Fursemide 40-0-0mg (post poned)/BPS>100mmHg Inj. Metoclopramide 3x10 mg (prn) HD elective if BPS>100mmHg
3. HF ST C FC IV
O2 2-4 LPM NRBM Semifowler potition fluid balance negative 0cc/24h durante shock condition Lowsalt <2gr/d Inj. Furosemide as above (post poned)
4 Cardiac tamponad e
4.1Uremic pericarditis dt o 2
History Efusi perikard before from Echo Diagnosed CKD since 2 years ago SOB General weakness PE: BP: 80/40 PR: 52 weak RR: 24 JVP R+4 Cm H2O Marvel sound (+) CXR: cardiomegaly and suggested cardiac tamponde ECG: sinus tachycardia with HR 105 bpm, OMI anterior wall Male/27yo/W. 25 A: Diagnosed CKD since 2 years PE: Pale conjungtiva (+) Lab: Hb: 6.40 MCV: 77.30 5. Anemia HM 5.1 Chronic disease dt CKD st 5 5.2 def FE 5. 3 Def folic acid 5.4 Def EPO Reticul osit count, SI, FE TIBC
S, VS , CBC
MCH: 24.20
Male/27 yo/W. 25 Lab: K:6.29 RBS: 90 6. Hyperpota semia
6.1 dt no 2
Inj. Ca glukonas 1 amp IV Inj. D40 2 flash IV Inj. Rapid acting insulin 10 iu IV
SE level, ECG
therapy
Time: 11:00 GCS 356 BP: 80/40 RR: 24 PR: 52 weak T: 37.8 Drip dobutamin(2-20mcg/kgbw/min) O2 8-10 lpm NRBM PO: inj. Antrain intravena Thorax and ECG cito at ER with high risk, KIE (+) BGA: waiting result DL, Ur, Cr, SE, Albuin, OT, PT waiting resul
11:15 GCS 346 GCS 356 BP: 80/40 RR: 28 PR: 50 weak T: 37.5 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
11:30 GCS 356 BP: 80/50 RR: 32 PR: 88 weak T: 37.5 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
11::45 GCS 346 BP: 80/50 RR: 32 PR: 92 weak T: 37.3 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
12:00 GCS 346 BP: 90/50 RR: PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
12:15 GCS 346 BP: 90/50 RR: 36 PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
12:30 GCS 346 BP: 90/50 RR:38 PR: 90 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
12:45 GCS 346 BP: 90/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutamni(2-20mcg/kgbw/min) continued O2 8-10 lpm NRBM
13:00 GCS 346 BP: 110/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutami(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM Consult to cardiology for cardiac tamponade
13:15 GCS 346 BP:110/50 RR: 38 PR: 98 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM
13:45 GCS 346 BP:110/50 RR: 36 PR: 100 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) maintenance O2 8-10 lpm NRBM
14:00 GCS 346 BP:90/40 RR: 31 PR: 92 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued increase O2 8-10 lpm NRBM
14:15 GCS 233 BP:80/palpatoar RR: 16 PR: 20 weak T: 36.8 Drip dobutamin(2-20mcg/kgbw/min) continued increase O2 8-10 lpm NRBM
14:20 GCS 111 BP:difficult to evaluated RR: - PR: - weak T: 36.9 Bagging, CPR 30:2 Inj. Adrenalin 1 amp IV