041011 ckd tn. supriyadi-rev

7/31/2019 041011 Ckd Tn. Supriyadi-rev

1/16

Wednesday , October 5th 2011

PHYSICIANS INCHARGE:IA : dr. Ade, dr. Suyoso, dr. WidyoIB : dr. Dyah, dr. Satryo

II : dr. M. hidayatIII : dr. Atma Gunawan, SpPD-KGH

MODERATOR: Dr. Gatoet Ismanoe ,Sp PD-KPTI


2/16

Summary of Data BaseMr. Supriyadi/ 56yo/w 24b

Chief Complain : nausea and vomiting

Patient suffered from nausea and vomiting since 1

week ago. Nausea almost every time he eat, sometime

accompanied by vomiting. It made he lost his appetite.

He said that since 10 days ago, his urine was reddish,

especially when he felt pain on his back. But his urine

become clear again when he drank more water. 20 days

ago, there were 5 pieces of small stone came out when

he passed urine.


3/16

he said that 6 months ago, his blood pressure was160/.. But he never consumed antihypertension andnever check his blood pressure anymore.

he took pils pasak bumi and neorheumacyl almosteveryday for about 6 years.


4/16

Physical examinationBP = 190/100 mmHg PR = 100 bpm RR = 20 tpm reg Tax : 37,0 C

General appearance looked moderatey ill GCS 456

Head Anemic -

Neck JVP R + 2 cmH 2O

Thorax: Cor: Ictus invisible and palpable at MCL ICS V SLHM ictus, heart waist +

RHM: SL DextraNo additional hearth sound

Lung: Symetric, SF D = S, s s v v Rh - - Wh - -s s v v - - - -

s s v v - - - -

Abdomen soefl, liver span 8 cm, troube space tympani, bowel soundnormal

Extremities Edema (-), anemic (-)


5/16

Laboratory findingLab Value Lab Value

Leukocyte 12,000 3.500-10.000/L Natrium 123 136-145 mmol / L

Haemoglobine 11.6 11,0-16,5 g/dl Kalium 7.79 3,5-5,0 mmol / L

PCV 33.8 35-50% Chlorida 102 98-106 mmol / L

Trombocyte 145,000 150.000-390.000/L CalsiumPhosphor 8.712.34 7.6-1 1mg/dl2.5-7.0 mg/dl

SGOT 19 11-41U/L Ureum 256.0 10-50 mg/dL

SGPT 15 10-41U/L Creatinine 30.91 0,7-1,5 mg/dL

RBS Albumin

853.60 3,5-5,5 g/dL

eGFR 2.6


6/16

Lab Value Lab Value

Urinalysis 10 x

SG 1.020 Epithelia +

PH 5.0 Cylinder -

Leucocyte +3 Hyaline -

Nitrite+ Granular -

Protein +4 Leukocyte -

Glucose + Erythrocyte -

Erythrocyte +5 40 x

Eritrosit >200Keton urine - Leukocyte 20-25

Urobilinogen - Crystal

Bilirubin - Bacteria +


7/16

BLOOD GAS ANALISISpH : 7. 227pCO2 : 26.3 mmHg

pO2 : 104.8 mmHgHCO3 : 13.2 mmol/LO2 sat : 96.9 %

BE : -16.9 m mol/LConclussion : metabolic acidosis


8/16

ECG 04/10/11


9/16


10/16

CXR 04-10-2011


11/16

CUE AND CLUE PL ID PD PT PM


12/16

CUE AND CLUE PL IDx PDx PTx PMo

Male/ 56 yo

Nause andvomitingReddish urineHistory of passedurine with smallstoneNSAID for 6 yearsBP 190/100PR = 100 bpm

Leukocytosis12,000Ur 256 Cr 30.91eGFR 2.6K 7.99Phosphor 12.34

Eritrosituri 5+Proteinuria 4+Leukosituria 3+BGA metabolicacidosisECGT tall in lead II,aVF, V3,V4, V5

1. CKD st5

1.1Obstructiveuropathy1.2 GNC1.2 PNC

BNOUSG

Abdomen

O2 2-4 lpmIv plugKidney diet 1900kcal/dayLow salt


13/16


Male/ 56 yo

Reddish urineHistory of passedurine with smallstoneNSAID for 6 years

BP 190/100PR = 100 bpm

Lab :Leucocytosis12,000Ur 256Cr 30.91eGFR 2.6K 7.99Phosphor 12.34Eritrosituri 5+Proteinuria 4+Leukosituria 3+

2. HT st 2 2.1 renalparenchymal2.2 primary HT

FunduscopyLipid profile

Low saltPo Nifedipine 3x 10mg

VSBP


14/16


Male/ 56 yo

Nause andvomitingReddish urineHistory of passedurine with smallstone

Ur 256

Cr 30.91eGFR 2.6K 7.99Phosphor 12.34

ECGT tall in lead II,aVF, V3,V4, V5

3.Hiperpotassemia

3.1 due toCKD st 5

Insulin 10 iu ivD40% 2 flashCa Gluconas 1 A

Hemodialisa as above

SEECG


15/16


16/16

041011 ckd tn. supriyadi-rev

Documents