Renal Cell Carsinoma

1. 1. Abdominal mass + pain, limfadenopathy aorta, Hidonefrosis sinistra,
Polipoid mass VU
2. Moderate Anemia MH
3. DM tipe 2 hiperglikaemia state non critical ill non obese
4. UTI complicata
5. Azotemia
6. Trombositosis
7. Severe hipoalbuminemia
8. Leukositosis
9. Mild dehydration
PROBLEM LIST
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

2. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Lump at stomach since 3 years. Initially a lump in the left stomach,
getting bigger until lower stomach.
• The stomach feels full, sometimes feels pain at left flank region
• Weight loss since last month
• Decreased appetite (+), nausea vomiting (-)
• Regular menstruation every month
1. Abdominal mass +
pain, limfadenopathy
aorta, Hidonefrosis
sinistra, Polipoid mass
VU
1.1 Malignancy
Mass
1.1.1 Renal Cell
Carcinoma
1.1.2 Lymphoma
maligna
1.2 Benign Mass
1.2.1 simple renal
cyst
1.2.2 polycystic
kidney disease
Renal Biopsy Non-Pharmacology:
No alcohol, no
smoking, less sugar
consumption
Drink enough water 1
L/day
Diet DM 1.345 kcal
/day
Pharmacology:
Confirm diagnose first
Inj Parasetamol 1
gram/8h
Plan Monitoring:
• VAS
• Vital sign
• Ur Cr
• UL evaluation
• USG Abdomen
Plan Education:
• If the pain increases
contact health workers
• eat little but gradually
• Explain about plan to
confirm the diagnosis
with biopsy
• Give information about
the disease
Objective:
UO: 450cc/24 h
BC: 0.4 cc/kgbb/h
VAS : 3
lymph node enlargement (-)
Abdomen: convex, palpable solid
mass a/r epigastrium,
hypochondriac sin, lumbar sin,
iliac sin sd suprapubic,
boundaries are not firm,
tenderness (+) spleen difficult to
evaluate, hepar not palpable
Laboratory Findings 18/6/23
Leucosit 19.300 / Neut% 82.5 / Limf%
12.6
Ur 61 / Cr 1.87
eGFR 33 / BUN: Cr = 15
UL 8/6/23
Blood 2+
Sedimen: Eritrosite 5-10, leuco 10-25,
epitel 10-15
Abdominal Contras CT Scan 6/6/23
- Gigantic left hydronephrosis, left
ureteropelvic junction stenosis ec
effect, multiple para-aortic and para-
iliac lymphadenopathy
- Polypoid filling defect on the right
side of the bladder size +/-1.2x1x2.6
cm

3. CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Weaknes (+)
• Look pale
• Weight loss since last month
• Decreased appetite (+), nausea vomiting (-),
swallowing pain (-)
• Bloody stool (-), bloody urine (-)
2. Moderate Anemia
Micrositic Hypocromic
2.1. Chronic disease
2.2. Iron deficiency
Blood smear
SI, TIBC, ST, Feritin
Non-Pharmacology:
Oxygenation
Pharmacology:
Transfusion PRC 1 pack/day
PRC Needed :
Correction of target Hb 10
(10-8.9) x 45 x 4 = 198 = 1 kolf
PRC
Plan Monitoring:
• Weakness
• HR, SpO2
• Urin production/day
• Bleeding manifestation
• Overload sign
Plan Education:
• Bed rest in bed
• Report any transfusion
reactions occured
• Explain to the patient if
complaints of weakness
increase or chest pain are
reported to the health
worker
• Report if any bleeding
manifestations happen
Physical
Examination:
Conj anemis (+)
atrophy of the
papillae of the
tongue (-)
Spoon nail (-)
RT: melena (-),
blood (-)
Lab 18/6/23
Hb 8.9, MCV 61.4, MCH 20.0
Lab 12/6/23 (post transfusion)
Hb 12.46 /MCV 62.6 /MCH
62.6
Lab 8/6/23
Hb 7.8, MCV 56.9, MCH 18.4
INITIAL PLAN

4. CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• DM since 3 year ago, with herbal medicine, highes
blood sugar 400
• Since last 1 weeks on detemir 0-0-10 iu
• Polyphagia (-) Polydipsi a(-) Polyuria (-)
• Decreased appetite (+), nausea vomiting (-),
3. DM type 2 hyperglicemia,
non critical ill, non obese
Non Pharmacology
Diabetes Diet
(25 x BB ideal) = 25 x 46.8 = 1170 kcal
• +10% (activity)
• - 5% (40 – 59 yo)
• + 10 % (ilness)
= 1.345 kcal /day
Protein 0.8 gr/kgbb/d = 37.4 gr = 149 kcal
Carbohydrate:
55% x 1.345 kcal = 740 kcal = 185 gr
Fat : 456 kcal = 50 gr
No alcohol, no smoking, less sugar
consumption, extra egg white
Drink enough water 1 L/day
Pharmacology
Loading 1000cc NS in 8 hours, then the
1000cc NS in 16 hours
Maintenance NS 1500 cc/24 h
- Detemir 0-0-10 IU
- Aspart 3x10 IU
Consider to give:
- Atorvastatin 0-0-20 mg
Planning Monitoring:
• Premeal BG, Bed time
BG
• HbA1C
• Profil lipid, ASCVD
score
Planning Education:
• Educate the patient
about the disease
Diabetes Mellitus
• Probability of taking
medicine for rest of
her life
• Educate about calories
amount her should
take and her diet
Physical Examination:
Weight : 45 kg
Height : 152 cm
Lab 18/6/23
RBG 418 mg/dl  375
mg/dl (after
rehydration)
Lab 09/06/23
FBG 331, 2HPP 345
Urinalysis 08/06/23
Clarity: cloudy
Glucose: 3+
Urinalysis 08/06/23
Clarity: cloudy
Glucose: 1+
INITIAL PLAN

5. CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Low back pain and lower stomach
• Fever since yesterday
• Pain when urinating (-)
• Urinate decrease, low back pain, fever since
yesterday
• DM (+) since 3 years ago
4. AFI Day 2 with
Abdominal pain,
Leucocyturia +
Bacteriuria
4.1 UTI complicata
4.2 Asymptomatic
bacteriuria
Culture sensitivity
urine
Non Pharmacology
No alcohol, no smoking, less sugar
consumption, extra egg whites
Drink enough water 1 L/day
Diet DM 1.345 kcal /day
Pharmacological
Inj. Ciprofloxacin 400 mg/12jam
Inf. Paracetamol 1 g/8 jam
Planning Monitoring:
• UL
• Sign of infection
• Temprature, BP
Planning Education:
• OUE hygine
• Don't hold urinate
• Sign of infection, or
septic
Physical Examination
T: 38.8
VAS 3
Abdomen:
suprapubic pain (+)
Lab 18/6/23
Leulosit 19.300, Neut% 82.5,
Limf% 12.6
Urinalysis 08/06/2023
Cloudy
Prot-Albumin 2+
Sediment Urine, leucosite 2+
Leucocyte 10-25
Eritrosit 5-10
Bacteri 1+
Urinalysis 18/06/2023
Cloudy
Prot-Albumin 3+
Sediment Urine, leucosite 1+
Leucocyte 5-10
Eritrosit 8-15
INITIAL PLAN

6. CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Weight loss since last month
• Decreased appetite (+), nausea vomiting (-)
• Urine approximately 2 glasses / day
• DM since 3 year ago
• HT (-)
5. Azotemia 5.1 AKI Stage 1
Acute insult : PNC,
volume depletion
Cronic insult: DKD
5.2 ACKD
Abdominal
Ultrasound
Non Pharmacology
No alcohol, no smoking, less sugar
consumption, extra egg whites
Drink enough water 1 L/day
Diet DM 1.345 kcal /day
Pharmacology
Rehydrate according to mild to
moderate dehydration :
• 109/100 x 45 x 30 = 1471 +
maintenance 1500cc = 2971 cc
Loading 1000cc NS in 8 hours, then
the 1000cc NS in 16 hours
Maintenance NS 1500 cc/24 h
Planning Monitoring :
- Ur/Cr per 48 h
- Urine output
- Fluid Balance
- Sign and symtomps
of electrolit
imbalance
Planning Education
- Drink enough water
- Record the volume
of urine per day
- Explain the cause of
the patient's kidney
disorder
- avoid nephrotoxic
drugs
Physical
Examination:
UO: 450cc/24 h
BC: 0.4 cc/kgbb/h
Dry lip (+), dry
turgor (+)
Who dehydration:
7
Laboratory Findings:
18/06/23
Ur 61 / Cr 1.87
eGFR 33 / BUN: Cr = 15
K 3.7
08/06/23
Ur 58.5 / Cr 2.25
K 3.16
Urinalysis 08/06/2023
Cloudy
Prot-Albumin 2+
Sediment Urine, leucosite 2+
Leucocyte 10-25
Eritrosit 5-10
Bacteri 1+
Urinalysis 18/06/2023
Cloudy
Prot-Albumin 3+
Sediment Urine, leucosite 1+
Leucocyte 5-10
Eritrosit 8-15
INITIAL PLAN

7. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Head ache (-)
• History of one sided body weak (-), Sudden
black out (-), chest pain (-)
6. Trombocytosis 6.1. Reactive -
inflammation
6.2. Essential
Blood smear
Bleeding time
Non-Pharmacology:
(-)
Pharmacology:
Treat underlying disease first
Planning Monitoring :
• CBC evaluate
• Planning Education
• Explain about the
possible cause
Trombocytosis
• Educate to patient if
symptoms of chest pain,
breathless, head ache to
call a doctor
Phy. Exam:
Splenomegaly (-)
Lab 18/06/23
Tromb 505.000
Lab 12/06/23
Tromb 506.000
INITIAL PLAN

8. CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Decreased appetite (+), nausea vomiting (-)
• Lump at stomach since 3 years. Initially a
lump in the left stomach, getting bigger
until lower stomach
• History of foamy urine (-)
7. Moderate
Hipoalbuminemia
7.1. Renal loss
7.2. Extra renal loss
24 hour urine protein Non Pharmacology
No alcohol, no smoking, less sugar
consumption, extra egg whites
Drink enough water 1 L/day
Diet DM 1.345 kcal /day
Pharmacology
Albumin supplementation 3 x 2 caps
Consider to give:
Albumin flash 20% 100cc if Albumin <
2.5
Planning Monitoring :
- Edem
- Urine output
- Albumin evaluation
Planning Education
• eat high protein
foods like eggs, fish,
meat
Objective
Abdomen : shifting
dullnes (-), undulation
(-)
Edem (-)
Lab 08/06/23
Albumin 2.25
Urinalysis 08/06/2023
Prot-Albumin 2+
Urinalysis 18/06/2023
Prot-Albumin 3+
INITIAL PLAN

9. CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Fever since yesterday
• Urinate decrease, low back pain, fever since
yesterday
8. Leukositosis 8.1 Bacterial Infection
8.2 Paraneoplastic
syndrome
Blood smear
Blood culture and
sensitivity
Non Pharmacology
No alcohol, no smoking, less sugar
consumption, extra egg whites
Drink enough water 1 L/day
Diet DM 1.345 kcal /day
Pharmacology
Inj. Ciprofloxacin 400 mg/12jam
Inf. Paracetamol 1 g/8 jam
Planning Monitoring :
• Fever, abdominal
pain
• Temp
• UL evaluation
• CBC
Planning Edukasi
• Explain about step
for diagnosed the
disease and how to
treatment
Objective
T: 38.8
VAS 3
Lab 18/06/23
Leu19.300 / Neut%
82.5 / Limf% 12.6
Lab 12/06/23
Leu 12.4600 /N% 70.3/
L% 19.2
Lab 08/06/23
Leu 22.380 / Neut%
80.6 / Limf% 12.7
INITIAL PLAN

10. CUE AND CLUE Problem List Initial Diagnosis
Planning
Diagnosis
Planning
Therapy
Planning
monitoring
Mrs S/ 49 yo
• Decreased of appetite (+) weakness
• Urine approximately 2 glasses / day
9. Mild
dehydration
Non-Pharmacology:
No alcohol, no smoking, less sugar
consumption
Drink enough water 1 L/day
Diet DM 1.345 kcal /day
Pharmacology:
Rehydrate according to mild to moderate
dehydration :
• 109/100 x 45 x 30 = 1471 +
maintenance 1500cc = 2971 cc
Loading 1000cc NS in 8 hours, then the
1000cc NS in 16 hours
Maintenance NS 1500 cc/24 h
Planning Monitoring
:
• Nausea vomite
• SE per 72 h
• UO/Fluid Balance
• Planning
Education
• eat little but often
• Drink enough water
• Avoid dehydration
Phy. Exam:
UO: 450cc/24 h
BC: 0.4 cc/kgbb/h
Dry lip (+), dry turgor (+)
Who dehydration: 7
Lab 18/06/23
Na 126, Na
corrected 136
Osm 285
RBG 418 mg/dl
INITIAL PLAN

11. THEORY AND GUIDELINE
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

12. Problem Analysis
Herediter Non Herediter
• Smoking
• Obesity
• Hipertension
• Expose chemical (ex
trichloretil,benzene,ben
zidine,cadmium,herbici
de,vinil chloride
• Longer use NSAID
• Hep C infection
• Von hipel lindau
syndrome
• Papilary renal
carcinoma
• Birth hough dube
syndrome
• Hereditary renal
carcinoma
Renal cell carcinoma
RBC production
Disturbed function
renal
Anemia
DM tipe 2
Overgrowth size
Gigantic Hidonefrosis
sinistra
Polipoid mass VU
AKI
Filtration
dysfunction
Hipercatabolic
Hipoalbumin
Paraneoplastic
Leucocytosis
+
Trombocytosis
Hiponatremia

13. RCC
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

19. Anemia
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

22. Type II Diabetes Mellitus
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat / RSUD Ulin Banjarmasin

29. AKI
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

33. UTI
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

34. RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL
UTI Common cause of UTI
• Female anatomy
• Sexual activity
• Certain types of birth
control. Menopause
• Urinary tract
abnormalities
• Blockages in the urinary
tract
• A suppressed immune
system.
• Catheter use
• A recent urinary
procedure.
MayoClinic
Female Anatomy

35. RISK FACTOR ANALYSIS

37. diagnose
Urinalysis
• For symptomatic UTIs, most patients have more than 10 leukocytes/
mm
• Presence of nitrite on a urinalysis is another marker of UTIs
• Bacteri does not always indicate positive or negative result since the
possibility of contamination or low bacteria burden

38. MANAGEMENT ANALYSIS UTI

44. HIPOALBUMIN
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat / RSUD Ulin Banjarmasin

47. Hyponatremia
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin

50. THANK YOU
PPDS-1 Ilmu Penyakit Dalam - Fakultas Kedokteran Universitas Lambung Mangkurat/ RSUD Ulin Banjarmasin