1. dr. Febri
MORNING REPORT
Tuesday, September 18th 2017
INTERNAL MEDICINE DEPARTMENT
MEDICAL FACULTY BRAWIJAYA UNIVERSITY | Dr. SAIFUL ANWAR GENERAL HOSPITAL
PHYSICIAN IN CHARGE :
JAGA I : dr. Arum, dr. Rokhma, dr. Fatoni, dr. Yudi
JAGA II CVCU : dr. Handy
HCU : dr. Febri
ER : dr. Fadhila, dr. Rahmad
Chief : dr. Regy
Consultant : dr. Didi C, SpPD-KPTI
Fasilitator : dr. Bogi Pratomo, Sp.PD-KGEH
2. Summary of Data Base
Mr. P/ 67 yo/W.26
Chief complaint : Shortness of breath
Present Illness :
Patient presented to our ER with the chief complained shortness of breath since 2
days ago and getting worse. He could not sleep well in the night, often awake in the middle of the
night because of shortness of breath, he sleep in half sitting position. The shortness of breath
relieve if she take a rest. He already felt shortness of breath since 4 months ago. He already
discharged from RSSA since 4 days ago. He admitted because bilateral leg swelling, then to his
arms. He felt bilateral leg swelling since 3 months ago, especially in the morning.
He felt nausea and vomiting once today since 3 days ago, sometimes accompanied by pain at
epigastric. He felt that his urinate in small volume since 3 days ago.
He also felt itchy at his leg and stomach.
He was diagnosed CKD since 2 weeks ago and got Hd 3 times when he admitted. After Hd, leg
swelling relieved.
3. Summary of Data Base
He got hypertension since 3 years ago. The highest BP was 200/.... He got medication but didnt
controlled.
Present medical history
At 2013, he admitted to RSSA beacuse his trombosit and leukosit was increasing. He diagnosed
trombositosis essensial after BMP. After discharged, patient didnt control buat take hydroxi urea.
Family History:
History of hypertension (+) his sister
History of DM (-)
Social History:
He is a farmer, live with his wife and has 4 son and daughter
4. Physical Examination
BP = 100/70 mmHg PR =96 bpm, regular RR = 28 tpm,
SpO2: 99%, O2 10lpm
NRBM
Tax : 36.3°C
General appearance looked moderately ill GCS 456 Looked normoweight
Head Pale conjunctiva +
Icterus Sclera -
Neck0 JVP R + 3 cmH2O 60 degree, lymphnode enlargement -
Chest Heart: Ictus invisible and palpable at ICS V at 1 cm lateral MCL Sinistra
LHM ~ ictus, heart waist ( -)
RHM ~ SL D
S1, S2 single, murmur -
Lung: SF D=S Rh - - Wh - - V V S S
- - - - V V S S
+ + - - V V S S
Abdomen Soefl, normal bowel sound, traube space tympani, liver span 10 cm,
shifting dullnes (-)
Extremities extrimities edema +/+ dry skin +,
5. Laboratory Findings
Lab Result Normal Value Lab Result Normal Value
Leukocyte 2760 3,500-10,000/µL Sodium 134 136-145 mmol /
L
Hemoglobine 10.7 11.0-16.5 g/dl Potassium 4.89 3.5-5.0 mmol / L
MCV
MCH
73.8
22.8
80-97 µm3
26.5-33.5 µm3
Chloride 104 98-106 mmol / L
275-285
PCV 34.7 35-50% RBS 101 <200 mg/ dL
Thrombocyte 136000 150,000-
390,000/µl
Ureum 132.2 10-50 mg/dL
SGOT 54 11-41U/L Creatinine 2.34 0.7-1.5 mg/dL
SGPT 65 10-41U/L Osm 283 275-295
Diff Count 1.4/0.7/68.2
/26.4/3.3
Albumin 4.14 3.5-5.5 g/dL
2.5-3.5 g/dL
Anti HCV Reactive NR eGFR 29.56
CCT (4 sept
2017)
6.62
10. CX-Ray Interpretation
Position, Intensity AP, Asymmetric, enough KV, Less inspiration
Trachea In the middle
Soft Tissue Normal
Bone Normal
Hemidiaphragma D domshape, S covered by cardiac shadow
Pulmo Increase of bronchovascular pattern
Cor Size enlargement; CTR 65%
Ictus embedded; Cardiac Waist (+)
Conclusion Cardiomegaly, edema pulmonum, efusi pleura D
13. Cue & Clue Problem
List
Initial
Diagnose
Planning
Diagnose
Planning
Therapy
Planning
Monitoring &
Planning
Education
Mr. P/57 yo/W.26
Subj:
Shortness of breath
PND (+), DOE (+),
Physical Examination:
BP= 100/700 mmHg;
HR= 96 x/m;
RR= 28 x/m;
Tax= 36
Konj Anemic (+)
JVP R+3 cmH20
palpable at ICS V at 1 cm
lateral MCL Sinistra
Rhonki +/+
Edem extremity (-/-)
Lab:
Hb 10.7
Ur 132.2
Cr 2.34
eGFR 29.56
BGA : metabolic acidosis
CXR : cardiomegaly, edema
pulmonum, efusi pleura D
USG Abd: chronic renal
disease bilateral, efusi pleura
bilateral, asites, congestive
liver
1. SOB 1.1 ALO non
cardiogenik
1.1.1
overload
syndrome
1.1.2 uremic
lung
1. 2 ALO
cardiogenic
1.2.1 HF st c
fc 3
NT pro
BNP
O2 8-10 lpm
Bed rest
Semifowler position
Fluid restriction
Renal diet 1500kcal/d, low
salt<2 g/day, protein 1-
1,2g/KgBW/day (if HD),
Folley Cathether inserted
Fluid balance -500cc/24 jam
IV: furosemid 3x40mg
Cito hemodialisa (done)
Subjective
Vital sign
Rhonki
Urine output
Fluid balance
BGA
Planning
Education:
The condition
Fluid
restriction
14. Cue & Clue Problem
List
Initial
Diagnose
Planning
Diagnose
Planning
Therapy
Planning
Monitoring &
Planning
Education
Mr. P/57 yo/W.26
Lab:
Thr 136000
BMP:
tromboscitosis essential
2. trombositosis
essential
- Hydroxyurea 3x500mg po
(stop)
Alupurinol 1x100mg po
VS, Subj,
CBC/3 days
15. Cue & Clue Problem
List
Initial
Diagnose
Planning
Diagnose
Planning
Therapy
Planning
Monitoring &
Planning
Education
Mr. P/57 yo/W.26
Subj:
• SOB
• History of HT (+) 3 years ago
• diagnosed CKD 2 weeks ago
and got Hd 3 times and leg
swelling relieved.
Physical Examination:
BP= 100/700 mmHg;
HR= 96 x/m;
RR= 28 x/m;
Tax= 36
JVP R+3 cmH20
palpable at ICS V at 1 cm
lateral MCL Sinistra
Rhonki +/+
Edem extremity (+/+)
Lab. Findings:
Hb 10.7
Ur 132.2
Cr 2.34
eGFR 29.56
CCT 6.62
CXR : edema pulmonum
BGA : metabolic acidosis
USG Abd: chronic renal
disease bilateral
3. CKD st 5 3.1 thrombosis
renal vascular
3.2 HT
nephrosclerosis
Fluid restriction
1000cc/day
Fluid balance (-) /24H
Renal diet 1500kcal/d,
low salt<2 g/day,
protein 1-
1,2g/KgBW/day (if HD),
Hemodialisa as schedule
Planning
Monitoring:
Subjective
Vital Sign
Fluid Balance
Urine Output
Hb
Ur/Cr
Planning
Education:
The condition
The diet
Physical
activities
Information
about Renal
Replacement
Therapy
16. Cue & Clue Problem
List
Initial
Diagnose
Planning
Diagnose
Planning
Therapy
Planning
Monitoring &
Planning
Education
Mr. P/57 yo/W.26
Subj:
PND, DOE, leg swelling
Physical Examination:
BP= 100/700 mmHg;
HR= 96 x/m;
RR= 28 x/m;
Tax= 36
JVP R+3 cmH20
palpable at ICS V at 1 cm
lateral MCL Sinistra
Rhonki +/+
Edema extremity (+/+)
USG Abd: congestive liver
ECG: LVH
CXR : edema pulmonum,
cardiomegaly
4. HF st C
Fc III
4.1 HHD
4.2 Uremic
Cardiomipat
hy
Echocardi
ography,
Bed rest
Semifowler position
Fluid restriction
Renal diet 1500kcal/d, low
salt<2 g/day, protein 1-
1,2g/KgBW/day (if HD),
Folley Cathether inserted
Fluid balance -500cc/24 jam
IV: furosemid 3x40mg
VS, Subj,
17. Cue & Clue Problem
List
Initial
Diagnose
Planning
Diagnose
Planning
Therapy
Planning
Monitoring &
Planning
Education
Mr. P/57 yo/W.26
Subj:
got Hd 3 times before
when he admitted
Lab. Findings:
Anti HCV Reactive
SGOT 54
SGPT 65
5. Hepatitis C HCV
Genotype
Confirm diagnosis VS, Subj,
jaundice
Mr. P/57 yo/W.26
Physical Examination:
Pale conjunctiva +
Lab
Hb 10.7
MCV 73.8
MCH 22.8
6. Anemia HM 6.1 drug
induced
(hydroxiurea)
6.2 dt no 3
SI TIBC sat
trasnferin
Treat underlying
disease
VS, Subj, Hb,
CBC /3 days
Mr. P/57 yo/W.26
Lab:
Leukocyte 2760
7. Leukopenia 7.1 drug
induced
(hidroksiurea)
Hydroxyurea 3x500mg
po (stop)
VS, Subj,
CBC/3 days
18. Risk Factor Analysis
Chronic Kidney Disease :
1. Diabetes
2. High Blood Pressure ( hypertension)
3. Heart disease
4. Smoking
5. Obesity
6. High cholesterol
7. African-American, American-India or Asian-American
race
8. A family history of kidney disease
9. Age 65 or older
19. Problem Analysis
CKD stg V
Metabolic Acidosis
Anemia HM
Acute Lung Oedema
Thrombocytosis
Essential
Hepatitis C
Thrombosis renal
vascular
Leukopenia
Drug induced
Volume Overload HF st C
20. RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL
CKD st V Risk Factor of CKD that
undergone HD
Glomerulonefritis
Diabetes Melitus
Obstruction and infection
Hypertension
Other Causes
PAPDI
Hypertension
Trombocytosis essensial
21. RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL
Anemia N-N Increased Red Blood Cells Loss or
Destruction
• Acute Blood loss
• Hypersplenism
• Hemolytic Disorders
Decreased red blood cell production
• Primary Causes : Marrow Hypoplasia,
Myelopathies
• Secondary Causes : Chronic Renal
Failure, Liver disease, Endocrine
deficiency states, Anemia of chronic
disease, sideroblastic anemia
Overexpansion of Plasma Volume
• Pregnancy
• Overhydration
AAFP
Chronic Renal Failure
Trombocytosis on treatment
with hydroxiurea
23. Management analysis
Theory Factual
Anemia Iron deficiency anemia. Treatment for this form of anemia
usually involves taking iron supplements and making changes to
your diet.
If the underlying cause of iron deficiency is loss of blood —
other than from menstruation — the source of the bleeding
must be located and stopped. This may involve surgery.
Vitamin deficiency anemias. Treatment for folic acid and B-12
deficiency involves dietary supplements and increasing these
nutrients in your diet.
If your digestive system has trouble absorbing vitamin B-12 from
the food you eat, you may need vitamin B-12 shots. At first, you
may receive the shots every other day. Eventually, you'll need
shots just once a month, which may continue for life, depending
on your situation.
Anemia of chronic disease. There's no specific treatment for
this type of anemia. Doctors focus on treating the underlying
disease. If symptoms become severe, a blood transfusion or
injections of synthetic erythropoietin, a hormone normally
produced by your kidneys, may help stimulate red blood cell
production and ease fatigue.
Focus treating the
underlying disease
24. Key Message
Patophysiology:
• The uremic syndrome is characterised by a deterioration of biochemical and physiological functions
in parallel with the progression of renal failure. This results in a variable number of symptoms.
• Uremia (uremic syndrome) is a serious complication of chronic kidney disease and acute kidney
injury (which used to be known as acute renal failure). It occurs when urea and other waste
products build up in the body because the kidneys are unable to eliminate them. These substances
can become poisonous (toxic) to the body if they reach high levels.
• Prolonged or severe fluid buildup (edema) may make the uremic syndrome worse.
• Uremic syndrome may affect any part of the body and can cause:
1. Nausea, vomiting, loss of appetite, and weight loss.
2. Changes in mental status, such as confusion, reduced awareness, agitation, psychosis, seizures,
and coma.
3. Abnormal bleeding, such as bleeding spontaneously or profusely from a very minor injury.
4. Heart problems, such as an irregular heartbeat, inflammation in the sac that surrounds
the heart (pericarditis), and increased pressure on the heart.
5. Shortness of breath from fluid buildup in the space between the lungs and the chest wall
(pleural effusion).
http://www.webmd.com/a-to-z-guides/tc/uremia-topic-overview
25. Key Message
Kidney dialysis is usually needed to relieve the symptoms of uremic syndrome
Management CKD:
SLOWING THE PROGRESSION OF CKD
• Protein Restriction
• Reducing Intraglomerular Hypertension and
• Proteinuria
MANAGING OTHER COMPLICATIONS OF CHRONIC KIDNEY DISEASE
• Medication Dose Adjustment
PREPARATION FOR RENAL REPLACEMENT THERAPY
http://www.webmd.com/a-to-z-guides/tc/uremia-topic-overview
26. Key Message
Social:
• It is important to prepare patients with an intensive educational
program, explaining the likelihood and timing of initiation of renal
replacement therapy and the various forms of therapy available.
The more knowledgeable that patients are about hemodialysis
(both in-center and home based), peritoneal dialysis, and kidney
transplantation, the easier and more appropriate will be their
decisions. Patients who are provided with educational programs are
more likely to choose home-based dialysis therapy. This approach is
of societal benefit because home-based therapy is less expensive
and is associated with improved quality of life. The educational
programs should be commenced no later than stage 4 CKD so that
the patient has sufficient cognitive function to learn the important
concepts.
• Patient should be told that had to restrict intake fluid to prevent
shortness of breath and had to to HD regularly as schedule.
