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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
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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.
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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.
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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 (-)
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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
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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 +
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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
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ECG 04/10/11
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CXR 04-10-2011
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CUE AND CLUE PL ID PD PT PM
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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
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CUE AND CLUE PL IDx PDx PTx PMo
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
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CUE AND CLUE PL IDx PDx PTx PMo
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
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