PERSONAL DATA

Name: Cadua, Lito

Age: 41
Address: 24 Capua St. Magsambong, Quezon City
Date of Birth: August 13, 1968
Place of Birth: Bohol
Date of Admission: May 11, 2010 @ 12:05pm
Diagnosis: Chronic Kidney Disease
LABORATORY AND DIAGNOSTIC TEST
HEMATOLOGY
May 10, 2010 done at ER MED
TEST
RESULT
Hgb
Hct
RBC count
MCV
MCH
MCHC
RDW-CV
WBC Count
Neutrophils
Lymphocytes
Basophils
Monocytes
Eosinophils
Platelet
MPV

69
0.203
2.43
83.5
28.4
34.0
12.2
14.81
82.7
6.3
0.2
10.7
0.1
435
7.2

TEST

UNIT
g/L
10^12/L
fL
pg
g/dl
%
10^9/L
%
%
%
%
%
10^9/L
fL

RESULT

Sodium
120.5 mmol/L
Potassium
4.23 mmol/L
Comments: Na - done twice
May 11, 2010
TEST
Creatinine

RESULT
1681.46 umol/L

Comments: done twice

REFERENCE
RANGE
110-160
0.370-0.540
3.50-5.50
80.0-100.0
27.0-34.0
32.0-36.0
11.0-16.0
4.00-10.00
50-70
20-40
0-1
3-8
0.5-5.0
100-300
6.5-12
REFERENCE
RANGE
135-145 mmol/L
3.6-5.5 mmol/L

REFERENCE RANGE
0-31 months : 26.52-70.72
32 months-12 yrs. : 26.52-53.04
13-19 yrs.: 26.52-88.40
20-99 yrs.: 45-104

SIGNIFICANCE

SIGNIFICANCE

SIGNIFICANCE

May 14, 2010

TEST
Prothrombin Time
PT control
PT INR
PT% ACTIVITY
LABORATORY
EXAM
HBsAg

RESULT
16.4
13
1.35
65.0
RESULTS
Reactive

UNIT
sec.
sec.

NORMAL
11.3-15.3

70-100

ABSORBANCE
READING
1.66

TEST

RESULT

A/G Ratio
Cholesterol
Triglycerides
HDL-Direct
LDL-Calculated

0.7
2.28 mmol/L
1.07 mmol/L
0.79 mmol/L
1.00 mmol/L

CUT OFF
VALUE
1.000

SIGNIFICANCE

METHOD
USED
ECLIA

REFERENCE
RANGE

SIGNIFICANCE

SIGNIFICANCE

0.00-5.18 mmol/L
0.0-1.95 mmol/L
0.75-1.85 mmol/L
1.72-4.63 mmol/L

TEST
Calcium
Total Protein

RESULT
1.63 mmol/L
62.81 g/L

REFERENCE RANGE
2.10-2.60 mmol/L
0-1 month : 43.0-69.0
13mos.-3yrs.: 52-74
4-6yrs.: 56-77
7-10 yrs.: 65-83
11-19 yrs.: 61-80
20-99yrs.: 65-81
7-12 yrs.: 27-48
13-18 yrs.: 31-48
19-99 yrs.: 35-50

Albumin

26 g/L

Globulin

36.81

May 20, 2010

TEST

RESULT

UNIT

Creatinine

1747.50

umol/L

Sodium
Potassium

127
3.01

mmol/L
mmol/L

SIGNIFICANCE

REFERENCE
RANGE
Adults: 45-104
Neonate: 27-87
Infant: 14-34
Child: 23-68
135-145
3.6-5.5

SIGNIFICANCE

ABG RESULTS
May 10, 2010 done @ ER
Baro
762.8 mmHg
Temp.
37.0
C
A/F
adult
-------------------------------------------------------PO2
55.1 mmHg (+) (80.0 100.0)
PCO2
11.7 mmHg (--) (35.0 45.0)
pH
7.194 ( - ) (7.350 7.450)
tHb
SO2

6.7 g/dL
74.8%

Hct
31.4% ( - ) (35.0 50.0)
-------------------------------------------------------BE
-21.7 mmol/L
BEecf
-23.7 mmol/L
cHCO3st
7.2 mmol/L
P50
26.7 mmHg
ctO2
7.1 vol %

SO2 = 74.8%
CHCO3 = 4.4 mmol/L

Interpretation:

May 11, 2010 done @ ER

Baro
762.6 mmHg
Temp.
37.0
C
A/F
adult
---------------------------------------------------------PO2
147.8 mmHg (+) (80.0 100.0)
PCO2
10.3 mmHg (--) (35.0 45.0)
pH
7.255( - ) (7.350 7.450)
tHb
SO2

5.9 g/dL
98.4%

Hct
32.2% ( - ) (35.0 50.0)
----------------------------------------------------------BE
-20.8 mmol/L
BEecf
-22.7 mmol/L
cHCO3st
7.5 mmol/L
P50
26.7 mmHg
ctO2
8.6 vol %

SO2 = 98.6 %
CHCO3 = 4.5 mmol/L
Interpretation:

May 12, 2010

Baro
762.2 mmHg
Temp.
37.0
C
A/F
adult
---------------------------------------------------------PO2
125.8 mmHg (+) (80.0 100.0)
PCO2
9.9 mmHg (--) (35.0 45.0)
pH
7. 302 ( - ) (7.350 7.450)
tHb
SO2

5.5 g/dL
97.1 %

Hct
30.4% ( - ) (35.0 50.0)
---------------------------------------------------------BE
-19.9 mmol/L
BEecf
-21.6 mmol/L
cHCO3st
8.1 mmol/L
P50
26.7 mmHg
ctO2
7.8 vol %

SO2 = 97.1 %
CHCO3 = 4.8 mmol/L

Interpretation:

May 13, 2010

Baro

763.8 mmHg

Temp.
37.0
C
A/F
adult
---------------------------------------------------------PO2
153.9 mmHg (+) (80.0 100.0)
PCO2
11.2 mmHg (--) (35.0 45.0)
pH
7.288 ( - ) (7.350 7.450)
tHb
SO2

Interferences (3) 1022

Interferences (3) 1022

Hct
28.1 % ( - ) (35.0 50.0)
---------------------------------------------------------BE
-18.0 mmol/L
BEecf
-21.4 mmol/L
cHCO3st
9.7 mmol/L
P50
26.7 mmHg
ctO2
21.1 vol %

SO2 = 98.9 %
CHCO3 = 5.2 mmol/ L

Interpretation:

KUB ULTRASOUND
May 17, 2010

FINDINGS:
Right Kidney: 10.5 x 3.6 x 3.3 cm ; Cortical Thickness: 0.8cm
Left Kidney: 11.4 x 5.8 x 5.6 cm ; Cortical Thickness: 0.9 cm
The right and left kidneys are normal in size and show diffuse increase in parenchymal
echogenicity greater than that of adjacent liver tissue. The cortico-medullary junctions are distinct.
The renal sinuses are centrally oriented with no evidence of ectasia or lithiases. There is a welldefined anechoic structure in the superior pole of right kidney measuring 1.9 x1.6 cm. similar three
anechoic structures are noted in the left kidney, the largest one measuring 5.2 x 4.6 cm with thin
septations. The other smaller one measuring 1.3 x 1.5 cm on the superior pole.
The urinary bladder is adequately distended with urine containing urinary sediments. The wall is
thin and mucosa is smooth. No intravesical mass lesion noted.
There is evidence of minimal intraperitoneal fluid collection as seen on hepatorenal space
Similarly there is evidence of massive sonolucent fluid collection in the right hemithorax with an
approximate volume of 1700 ml.
IMPRESSION:
Renal Parenchymal Disease, Bilateral (Grade II)
Renal Cortical Cysts, Bilateral with (Bosniak I) on the right and (Bosniak II) on the left.
Suggest follow up study.
Massive Pleural Effusion, right
Minimal Ascites
Urinary bladder containing sediments. Please correlate clinically with other laboratory
parameters.

MEDICATIONS:
FeSO4 + Folic Acid OD
Calcitrol 1tab TID

Vitamin K 1amp TIV OD

Amlodipine 5 mg/tab OD increased to Amlodipine 10 mg/tab BID @ 5/15
Paracetamol 500mg/tab Q4H
Erythropoetin 400u SQ once a week not given
Omeprazole 40mg. TIV Q12H
NaHCO3 50meqs TIV SIVP given @ 5/11 only
Furosemide 40mg TIV Q12 increased to 80 mg @ 5/18 then discontinued @ 5/19
Atorvastatin 80mg tab OD discontinued @ 5/18
DIET: Uremic Diet
Limit OFI <1.2 L/day
Limit Na <2.3g NaCl <6g
Avoid Fruits and Fruit Juices
IVF:

from May 11, 2010

May 21, 2010

1. D5 0.3 NaCl 10gtts

2. PNSS 20gtts
3. D5 0.3 NaCl 10gtts
4. D5 0.3 NaCl 10gtts
5. D5 0.3 NaCl 10gtts
6. PNSS 30gtts
7. PNSS 30gtts
8. PNSS 30gtts

BLOOD TRANSFUSION: B+

5/14 @ 4pm-7:30pm
5/15 @ 4:30am- 8am

OPERATION (done @ 5/18): Tenckhoff Catheter Insertion

Surgeon: Dr. De Ramos

PERITONEAL DIALYSIS : started at 5/19 @ 1:30am

Materials:
PD straight catheter
Y tubing

Silk Strand round with needle 3.0

Lidocaine 50ml
PD Dialysate 1L 4.5% #15
PD Dialysate 1L 1.5% #15
-

For the first 2L, infuse 4.25 then drain

For the succeeding, alternate 1.5 and 4.5
Infusion Time: 10 mins
Retention Time: 30 mins
Draining Time: 20mins
For the 2nd 30 cycle, use 1.5% only