Morning Shift Report Saturday, 20-4-2013 dr.

dikara

Physician In Charge: 1A : dr. Dikara, dr. Zoraida, dr. Perdna (cardio) 1B : dr. Ananto, dr. Sigit II : dr. Heri III : dr. Bogi Pratomo Sp.PD-KGEH Summary of Data Base Male 17yo/ w.26 Chief complain : Shorthness of breath (heteroanamnesis with his father) Patient reffered to RSSA from RS. Ngudi Waluyo because renal failure, initially patient suffered from shorthness of breath since 3 days ago (RS. Ngudi Waluyo), and worsened since yesterday, Shorthness of breath not reileve by rest. He also complained seizure 1x at home before admission at RS.Ngudi waluyo, tonik klonik, 5 minute. He also complained about nausea,and vomiting accompanied with decrease of appetite since 3 days ago. History of hospitalized: when his patient 2 years old done operation with Sp.U because of difficult to urination and the doctor said prostat and then at 2012 history of done operation teropong with Sp.B History of DM (-), HT (-) He is a Student, last children, History of family:-

Physical Examination Ward: BP = 90/50 mmHg PR = 112 bpm,regular,weak RR = 28 bpm kusmaull Tax : 36,8C

General appearance looked severely ill Head Neck Chest Heart: Pale conjunctiva (+) JVP R + 2 cmH2O 45 degree

GCS 1X1 BW: 50kg BMI:18,37 Icteric sclera (-)

Ictus visible and palpable at ICS VI MCL Sinistra LHM ictus RHM: SLD S2>S1 single, murmur (-) Symmetric, SF D=S, normal percussion,

Lung:

Rh + + + + + + Abdomen Extremities

Wh - - - -

Soefl, Sound of bowel (Normal) liver span 10 cm, traubes space tympani, shifting dullness (-) Pitting edema +/+ , warm acral

Laboratory Finding (April 20th 2013 ) Lab Leucocyte Haemoglobine MCV MCH PCV Trombocyte SGOT SGPT Eo/Ba/Ne/Li/ Mo Value 40.080 8.3 70.60 24.90 23.50 221.000 30 13 0.0/0.0/91 .2/5.0/3.5 (Normal) 3.50010.000/L 11,0-16,5 g/dl 76-96 fl 26-34 35-50% 150.000390.000/L 11-41U/L 10-41U/L Lab Natrium Kalium Value 115 5.96 (Normal) 136-145 mmol/L 3,5-5,0 mmol/L

Chlorida RBS Ureum Creatinin eGFR

90 142 489.10 24.96 3.83

98-106 mmol/L < 200 mg/dl 20 40 mg/dL < 1.2 mg/dL

BGA April 20th 2013 PH : 7.07(N: 7.35-7.45) PCO2 : 21.6 mmHg (N: 35-45) PO2 : 86.9 mmHg (N: 80-100) HCO3 : 6.3 mmol/L (N: 21-28) O2 Sat Arterial: 92.2 (N > 95) BE: -24.1 mmol/L Conclusion: Severe asidosis metabolic

ECG ( April 21h 2013 ) Sinus tachycardia , HR 127 bpm Frontal Axis : RAD Horizontal Axis :N PR interval : 0.20 QRS complex : 0,10 QT interval : 0,32 P pulmonal : Lead I, II, V2, V3 Conclusion : Sinus tachycardia 127 bpm, hyperpotassemia CXR ( April 21 th 2013 )

AP position, symmetric, enough KV Soft tissue and bone: normal Trachea in the middle Sinus phrenicocostalis dextra and sinistra: sharp Hemidiaphragma dextra and sinistra: dome-shape Lung: BVP increase,Cephalisasion (+), radioopaque shadow at upper lung dextra Cor: site N, cardiac waist (+),size: CTR=75% Conclusion: Odem pulmo, mass at upper lung dextra?

CUE AND CLUE Male/17 yo A DOC SOB Nausea Vomitting History of operation twice PE GCS 1x1 TD: 90/50 mmHg PR: 112 regular, weak RR: 26 kusmaull Tax: 36.8 Lab: Hb: 8.3 Leu: 40.080 Trombo: 221.000 Ur: 489.10 Cr: 24.96 BGA: Severe Acisosis metabolic CXR: odem pulmo Male/17 yo A DOC SOB History of operation PE GCS 1x1 TD: 90/50 mmHg PR: 112 regular, weak RR: 26 kusmaull Tax: 36.8 Lab: Hb: 8.3 Leu: 40.080 Ur: 489.10 Cr: 24.96 BGA: Severe Acisosis metabolic CXR: odem pulmo

PL 1. DOC

IDx 1.1 Uremic enchepalop athy 1.2 SEPTIC CONDITION

PDx Head CTScan

PTx Jackson reese 10 lpm Inserted NGT Renal diet 1700kcal/day Protein 0.6-0.8 g/kgbw6x200cc Drip NE 0.05-0.2mcg/min Drip Dobutamin 520mcg/min until MAP>70 Inj. Metoklopramid 3x10mg (prn) Drip Nabic at ER Plan HD cito if transportable

PMo S, VS, Ur, Cr, UOP, BGA post corecti on

2. SOB

2.1 Uremic lung 2.2 Pneumonia CAP

Culture andsensitifi ty sputum

Jackson reese 10 lpm Inserted NGT Renal diet 1700kcal/day Protein 0.6-0.8 g/kgbw6x200cc Drip NE 0.05-0.2mcg/min Drip Dobutamin 520mcg/min until MAP>70 Inj. Metoklopramid 3x10mg (prn) Drip Nabic at ER Plan HD cito if transportable

S, VS, Ur, Cr, UOP, BGA post corecti on

Male/17 yo A DOC SOB Nausea Vomitting History of operation PE GCS 1x1 TD: 90/50 mmHg PR: 112 regular, weak RR: 26 kusmaull Tax: 36.8 Lab: Hb: 8.3 Leu: 40.080 Ur: 489.10 Cr: 24.96 eGFR: 3.83 BGA: Severe Acisosis metabolic CXR: odem pulmo Male/17 yo Lab: Hb: 8.3 MCV: 70.60 MCH: 24.90

3. CKD ST V newly diagnosed

3.1 Ig A nefropathy 3.2 PNC 3.3 GNC

USG Abdomen

Jackson reese 10 lpm Inserted NGT Renal diet 1700kcal/day Protein 0.6-0.8 g/kgbw6x200cc Inj. Metoklopramid 3x10mg (prn) Drip Nabic at ER Plan HD cito if transportable

S, VS, Ur, Cr, UOP

4. Anemia HM

4.1 Chronic disease dt no 3 4.2 Def. Fe

Blood smear SI,IBC, Ferritn serum ,

Jackson reese 10 lpm Inserted NGT Diet DM 1800kcal/day 6x200cc Transfusion 1 kolf durante HD

S, VS,CB C

Male/17 yo Lab: PH: 7.07 PCO2: 21.6 PO2: 86.9 HCO3: 6.3 O2 Sat Arterial: 92.2 Be: -24.1

5. Severe Acidosis metabolic

5.1 dt no 3

Bolus Nabic 90meq slowly Drip Nabic 90 meq in 500cc Ns0.9% 20 dpm micro (ER)

S, VS,BG A

Male17 yo Lab: Na: 115 Osm : 319

6. Hyponatrem ia hypotonic hypervolemi a

6.1 dt no 3

Inj. Furosemid 40-0-0 (if BPS>100)

SE level

Male/17 yo Lab: K: 5.96

7. Hyperpotas emia

7.1 dt no 3

Treat same aqbove

SE level