MORNING REPORT

Monday, February 24th 2014

Coass IN CHARGE:
Faizal Reza Pahlevi
Sri Lestari Fajrien

Moderator : dr. Syifa Mustika, Sp.PD

 SUMMARY OF DATA BASE
Male/48 yo/w. 25
Chief complaint : abdominal pain
patient complain about abdominal pain since 10 days before
admission, initially it was felt in the middle left side area and then in the last
2 weeks reffered to all area. It was like pressure sensastion.

He also complain about abdominal enlargement since 10 days before,

this is the first time, sometimes it was accompanied with bloating sensation
and nausea without vomiting, previously flatus was (-) but now its been
normal, and the last passing stool was yesterday.

He diagnosed as kidney failure since 6 years ago, and performed

hemodialysed routinely 1 time/week every thursday.
He had experienced of bloody urine, for 2-3x, about 25 years ago,
painless, and self limited. Never had stone nor sand urine.
Patient ever admitted 3 times before at RSSA:
1. 1988, beause of fall from coconut tree, doctor said he got vertebral
fracture, and suggested to do operation but he is refuse
2. At mei 2009, diagnosed as kidney failure
3. At august 2009, he got decreased of concioussness because of renal
complication

Social history:
He married, had 2 children. He smoking since youth about 12 bars/day and
stop about 15 years ago. He work as labour but already retired since 6 years
ago.
About 1-2 year before he diagnosed kidney failure, he often consume energy
drink such as extra joss or kukubima , about 3X/week and also traditional
potion jamu udekan about 1x/week.
 Physical examination
General appearance looked moderetely ill, Oxygen GCS 456
nasal canule 2-4 lpm, Looked normoweight
BP 140/80 mmHg RR 21 times/minute
PR 100 beat per minute regular strong Temp 36.7 C
Head Pale conjunctiva + Icterus Sclera -

Neck JVP R + 3 cmH2O (flat), lymphnode enlargement -/-

Chest Heart: Ictus invisible and palpable at ICS VI 1 cm lat MCL Sinistra
LHM ≈ ictus, heart waist (-)
RHM: SL D
S1, S2 single, murmur (-)

Lung: Symetric, SF D= S s s Rh - - Wh - - V V
s s -- - - VV
s s ++ --
Abdomen Rounded, bowel sound ( +) normal,
liver span 7 cm, traube space dullness, undulation (+), tender pain in all area of
abdomen
Genitourinary
Extremities pale +/+ , dry skin +, Capillary refil time < 2 second, edema (-)
Lab Value Lab Value
Leukocyte 13.190 3.500-10.000/µL Natrium 128  136-145 mmol / L
126
Haemoglobine 8.10 11,0-16,5 g/dl Kalium 6.12  3,5-5,0 mmol / L
MCV 84.50 80-97 fL 5.40
MCH 26.60 27-31 pg Chlorida 102  98-106 mmol / L
101
PCV 40.40% 35-50% RBS 109 < 200 mg/dL
Trombocyte 379.000 150.000- SGOT 9 11-41U/L
390.000/µL
Eo/Ba/Neu/Ly/ 0.8/0.2/82 0-4/0-1/51- SGPT 8 10-41U/L
Mo .6/9.9/6.5 67/25-33/2-5
Ureum 188.80 10-50 mg/dL Albumine 3.31 3.5-5.5

Creatinine 19.90 0,7-1,5 mg/dL Osmolarity 262 280-295 mOsm

eGFR 3.5 mL/min/1.73 m2
(cockroftgault
equation)
 URINALISIS
Lab Value Lab Value
Cloudy Turbid Clear 10 x
Color Yellow Yellow Epitel 42.1 ≤ 1lpf
pH 7,5 4,5 - 8,0 Cilinder - Lpf

SG 1.025 1,010 – 1,015 Hialin - ≤2

Glucose Negative Negative Granular - Negative
Protein 2+ Negative 40 x

Keton - Negative Erythrocyte 115.5 ≤ 3 hpf

Bilirubin - Negative Dysmorfic - Hpf
Urobilinogen - Negative Eumorfic 95% Hpf
Nitrit + Negative Leucocyte 2395.7 ≤ 5 hpf
Leucocyte 3+ Negative Cristal - hpf
Blood 3+ Negative Bacteria 480.9X10*3 ≤ 23 x 103/mL
others Fungi (+)
 Laboratory Finding
BGA Value (without Oxygen supplementation)
Oxygen 10 liters supplement

PH 7.36 7,35-7,45

PCO2 32.7 35-45

PO2 73.3 80-100

True O2

HCO3 18.8 21-28

O2 saturation 92% > 95%

Base Excess -6.8 -3 until +3

Conclusion Metabolic acidosis fully compensated with mild hypoxemia

 Ascites fluid analysis
Macroscopic

-colour Yellow Rivalta test Negative

- (+) SAAG 3.09 g/dL

-clarity Slightly turbid

Microscopic

-erythrocyte 150 /uL

count
-leucocyte 2310 /uL
count
-PMN 85% Absolute 1963
neutrophyl
count
-MN 15% Monocyte 347
count
Chemical

-protein total 0.75 g/dL

-Glucose 1 Mg/dL

-TG 9 Mg/dL

-cholesterol -2 Mg/dL

-LDH 3223 U/L

ECG (February 23 th 2014 )
 Electrocardiography (february 23th 2014)

• Sinus tachycardia, Heart rate 125 beat per minute

• Frontal Axis : Normal
• Horizontal Axis : Normal
• PR interval : 0.16”
• QRS complex : 0.08”
• QT interval : 0.32”
• Conclusion : sinus tachycardia with Heart rate 125 beat per
minute
Chest X-ray: February 24th 2014
 Chest X Ray (February 23th 2014)

• AP position, asymmetric, KV enough, less inspiration

• Soft tissue thin, Bone normal
• Trachea in the middle
• Hemidiaphragm D is flattening, S domeshape
• Phrenico costalis angle D/S sharp
• Pulmo D/S: bronchovesicular pattern normal
• Cor: site Normal , size: Cardio thoracis ratio 58%, shape: cardiac
waist (+), bootshape (+)

Conclusion : looked cardiomegaly

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Male/48 yo 1. 1.1 primary Ascites Oxygen 2-4 Sign of Acute Explanation

Abdomi bacterial fluid liter/minute abdomen about
History Taking
nal pain peritonitis culture via NC current
Abdominal pain
Initially localized then
+ Abdominal condition
spreading all area ascites 1.2 secondary Cefotaxim circumference
Previously flatus (-)  bacterial 3X2 gram (iv)
(+) peritonitis
Passing stool (+) Paracentesis
Nausea (+) ascites 1 liter
History of CKD (ER)
PE:
Abdomen : rounded,
soefl, undulation (+) ,
traube space dullness
(+)
Tender pain in all area
Ascites (+)

BOF: no sign of
perforation

Lab:
Leucocyte 13.900 u/L
Asites fluid analytic :
PMN 1963 /uL
LDH 3223 U/L
Rivalta test (-)
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Male/48 yo 2. 2.1 dt Ca gluconas 10% 1 ECG Causes

History taking : Hyperkal CKD ampul intravena
Diagnosed as emia stage D40% 50 cc SE
kidney failure 5 intravena
Routinely Short acting
hemodialysed 1 insulin 10 IU
time/week intravena

Lab: Furosemide 40-0-0

Ur/Cr 181.80 mg
mg/dL
eGFR 3.5 Calcium
ml/minute/1.73m2 polystirene
SE 128/6.12/102 sulfonate 3X5
mmol/L gram

Hemodialysed
elective
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Male/48 yo 3. CKD 3.1 GNC Renal Soft diet 1700 Urine Condit
History taking : stage 5 on 3.2 NSAID biopsy kcal/day low salt < 2 production ion,
Diagnosed as kidney routine nephr gram/day, protein 55 progno
failure
Routinely hemodialysed
HD opathy gram/day SE sed
1 time/week 3.3 PNC
History of consume Hemodialysed Ureum and
energy drink and elective creatinin
traditional potion

Physical examination:
Conjunctiva anemis (+)
Pale extremities (+)
Dry skin (+)
Undulation (+)
Lab:
Hb 8.10 gr/dL
MCV : 84.50 fl
MCH: 26.50 pg
Ur/Cr 181.80
/19.90mg/dL
eGFR 3.5
ml/minute/1.73m2
SE 128/6.12/102
mmol/L
Albumine 3.31 gr/dL
UL :
Protein 2+
Erythrocyte 115.3 hpf
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Male/48 yo 4. 4.1 Fraction Intravenous SE Condition,

History taking : Hyponatre dilut Excretion furosemide 40-0-0 prognosed
Diagnosed as mia iona Urine mg Status
volume
kidney failure Hypoosmol l
Routinely ar
hemodialysed 1 Hypervole
time/week mia

PE:
Undulation (+)

Lab:
Ur/Cr 181.80
mg/dL
eGFR 3.5
ml/minute/1.73m2
SE 128/6.12/102
mmol/L
Osm 260
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Male/48 yo 5. Re-check Antibiotic Pain in Hygiene

Decreased in Urinary UL Cefotaxim 3x2 urination
passing urine in tract gram
Urine
the last 10 days infection
production

Lab:
Leucocyte 13.190
/uL
UL
Nitrit (+)
Erythrocyte 115.3
hpf
Eumorfic 85%
Leucocyte 2395,7
hpf
Bacteria 480.9 X
10*3
Fungi (+)
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Male/48 yo 6. 6.1 Funduscopy Peroral diltiazem Blood Compliance

History taking : Hypertensi renop 3X30 mg pressure to
Diagnosed as kidney on stage 1 arench USG medication
failure
Routinely
ymal dopler Target
hemodialysed 1 hypert organ
time/week ension damage

Physical examination: 6.2

BP 140/80 mmHg hypert
ension
renov
ascula
r
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Male/48 yo 7. 7.1 uremic Iv metoclopramide Complain Explanati

History taking : Dyspepsia gastrop 3X10 mg on about
Nausea syndrome athy current
Diagnosed as kidney
failure
condition
Routinely
hemodialysed 1
time/week
History of consume
energy drink and
traditional potion

Lab:
Ur/Cr 181.80 /19.90
mg/dL
Thank You!