morning report ckd

8/19/2019 Morning report CKD

1/15

Morning ReportFebruary, 14th 2016


2/15

Summary of Data BaseAnamnesis :

Mrs. Suiati!4" yo! #. 26

• $hief %omp&aint : Shortness of breath 'atient su(ere) from shortness of breath sin%e si* month ago,

intermittent&y but +orsening in the &ast t+o )ays beforea)mission. n the &ast t+o )ays shortness of breath o%%urre) +hen

she )i) hea-y nor mi&) a%ti-ity su%h as +a& to the bathroom.Shortness of breath some+hat re&ie-e) by rest but in the &ast t+o)ays )i)nt re&ie-e) e-en she too a rest. She a&so s&ept on /pi&&o+s an) in the ha&f sitting position. She a&so often +oe up inthe night be%ause of shortness of breath.

She a&so su(ere) from nausea +ithout -omiting sin%e one+ee ago, be%ause of this %on)ition she a&so su(ere) from)e%rease of appetite, she on&y ate " 6 spoon of ri%e an) herfami&y reporte) that her bo)y +eight &ooe) sinny.

She a&so %omp&ain about %ough sin%e t+o )ays ago +ith

+hitish sputum espe%ia&&y in the morning sin%e she su(ere) fromshortness of breath, an) )i)nt a%%ompanie) +ith &o+ gra)e fe-er


3/15

She often %onsume) the tra)itiona& poison if she fe&t pain after she +ore).She use) to )o it sin%e she +as young.

She +as )iagnose) en) stage rena& fai&ure sin%e si* months ago, an) got

routine&y haemo)ya&isa t+o times per +ee e-ery Mon)ay an) hurs)ay, the&ast s%he)u&e of haemo)ya&isa about four )ays ago.

She a&so )iagnose) +ith hypertension sin%e one year ago, at that time theb&oo) pressure +as 200!...but she )i)nt routine&y %ontro&&e)

She a&so %omp&aint her passing urine +as )e%rease) sin%e she )iagnose)+ith en) stage rena& )isease, an) the -o&ume per )ay about 100 200 %%. 3o

history of )iabetes me&&itus

'ast me)i%a& history :

n the &ast si* months she hospita&ie) more than eight times at RSS5 be%auseof shortness of breath

Fami&y istory :

er mother su(ere) from hypertensionSo%ia& istory :

She is a pensioner, marrie), she has t+o %hi&)ren.

5&&ergi% history :

She )oesnt ha-e foo) an) )rug a&&ergi%

Me)i%ation istory :

She routine&y %onsume) irbesartan, furosemi)e, is)n, am&o)ipine, a& 7+henshe un)er+ent the hemo)ya&ie8


4/15

General appearance looked severely ill GCS : 456

BP= 234/140 mmHg(ER) 210/80 mmHg

(ward)

PR = 120 bpm (ER) 89bpm regular strog

(ward)

RR = 40 tpm(ER) 28 tpm

(ward)

!a" # 3$%$ 0&

Head Conjunctiva Anemic (+ !cteric ("

#eck $%& ' + 4 cm H) *)position

,ora- Heart !ctus invisi.le / palpa.le at cm lat !CS %! 0C1 S'H0 : S1 21H0 : ictus cordisS3 S sinle mur mur (reular alllop ("

1un Simetric S7 2 8 S s s v v ', + + (9' ', " "

s s .v .v ' ' + + s s .v .v ' ' + +

A.domen Soel ;S + # liver span < cm= Spleen impalpa.le trou.e spacetympani s,itin dullness ("

9-tremities &ittin 9dema " >" Acral : ?arm and dry +>+

'9S$5 ;


5/15

ab >a&ue73orma&8

ab >a&ue 73orma&8

euo%yte 12??0 4.@00 11./00 !A 3atrium 1// 1/614"mmo&!

aemog&obine

@,20 11,4 1",1g!)&

Ca&ium 4.2? /,"",0 mmo&!

RB$ 2,4 4.0 ".0106!A

$h&ori)a 10@ ?106 mmo&!

rombo%yte 260.000 142.000 424.000 !A

Ereum ?4,20 2040 mg!)

$reatinine ?,/@ 1,2 mg!)

aemato%rit

22,/0 G / 42 G eHFR6

m&!min!1.@2m2

M$> ?0.@0 0?/ I HDS 2@1 200M$

2?./02@/1 pg $a&sium

.@@.611.00mg!)

;o!Bas!3eu!&imf!Mon

0,"!0.2!1,0!1",!2,

"

04!01!"16@!2"//!2

"

=sm2@?

20 2?"mosm!g

SH= 2? 0/2 mE!) 5&bumin 4,26 /.""." g!)

5B=R5=R9 F3D3H 7140220168


6/15

BH5 +ith =2 10 &pm 3RBM 714!02!20168

>a&ue 3orma& >a&ue

' @./6 7.35-7.45

'$=2 2?,@ 35 – 45 mmHg

'=2

26/,0 80 – 100 mmHg

$=/ 1@,6 21 – 28 m mol/L

=2 sat 5rt ?@,@ G > 95 %

B; @,@ (-3) - (+3) m mol/L

b 6,?

rue =2 "",/? mmg 80 – 100 mmHg

$on%&usion : a%i)osis metabo&i% fu&&y %ompensate) +ithmo)erate hypo*emia


7/15

5B >5E; 5B >5E;

urbi)ity $&ear 10 *$o&our 9e&&o+ ;pithe&ia ",2

' 6,0 $y&in)er 3egati-e

SH 102" ya&ine

H&u%ose 3egati-e Hranu&ar

'rotein /J

Ceton 3egati-e 40 *

Bi&irubin 3egati-e ;rythro%yte /,1Erobi&inogen 3egati-e euo%yte 6,@

3itrite 3egati-e $rysta&

eu%o%yte 3egati-e Ba%teria "01,/ * 10

B&oo) 2J =thers

URINALYSIS February 14th 2016


8/15

;$H


9/15

$


10/15

$E; 53D $E; ' )* 'D* '* 'Mo 'e)u

Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort

'aro*ysma& 3o%turna&Dyspneu=rthopneu3auseaDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al

e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpmDry sin J5nemia $onun%ti-a

K>' L R J 4 %m207/08

$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JE=' "00 %%!12 hourLab %n!in&sb @,/ gr!)

Er!$r ?4,20!?,/@mg!)&

1.Shortness ofbreath

1.1 5%ute ung=e)ema

1.1.15%%e&erate)

hypertension

1.1.2 eartFai&ureStage $ F%>

1.1./ =-er&oa)syn)rome

;%ho%ar)iography

=2 10 &pm -ia 3RBMSemifo+&er positionBe) restn Furosemi)e 0 mg

> %ontinue +ithFurosemi)e )rip 20mg!hourDrip 3i%ar)ipine " 1" mg!hour unti& M5')e%rease 2" G7target 1@"!10"mmg8

3egati-e Iui)ba&an%e "00 %% per)ayemo)ia&ysis $ito

>S$omp&ainErine

pro)u%tion

F&ui)restri%tion,e*p&a

nationaboutrena&rep&a%ementthera

py


11/15

$E; 53D $E; ' )* 'D* '* 'Mo 'e)u

Female/45 yo/ar!26AnamnesisShortness of breath3ausea

Diagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#ale$aminationH$S 4"6B' 210!0 mmg'R ? bpm

RR 2 tpm K>' L R J 4 %m207/08$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eLab %n!in&sEr!$r ?4,20!?,/@

mg!)&eHFR 6m&!mnt!1.@/m2

2.ypertension;mergen

%y

2.1 ;ssentia&7primary8

2.2 Se%on)ary2.2.1

Renoparen%hyma&

2.2.2Reno-as%u&ar

=2 10 &pm -ia 3RBMSemifo+&er positionBe) restDrip 3i%ar)ipine "

1" mg!hour unti& M5')e%rease 2" G7+ithin 1 hour87target 1@"!10"mmg8'er ora& :rbesartan 00/00mg tab&et$&oni)in / * 0,1" mgtab&et

>S7b&oo)press

ure,M5'8$omp&ain

Disease,%omp&i%ati

on,targettreatment


12/15

$E; 53D $E; ' D* 'D* '* 'mo 'e)u

Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort'aro*ysma& 3o%turna&Dyspneu=rthopneuDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpm5nemia $onun%ti-a

K>' L R J 4 %m207/08$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JLab %n!in&sb @,/ gr!)Er!$r ?4,20!?,/@ mg!)&eHFR 6 m&!mnt!1.@/m2$entri%u&ar

/. eartFai&urestage $F$ >

/.1 ypertensi-eheart)isease

/.2 uremi%

%ar)iomyopathy

;%ho%ar)iography

=2 10 &pm 3RBMBe) rest3egati-e Iui) ba&an%e"00 %%!)ay

Semifo+&er positionFurosemi)e 7as abo-e8

>SSubF&ui)ba&an%e

Disease,treatment,

prognosa

$E; 53D $E; ' D 'D ' ' '


13/15

$E; 53D $E; ' D* 'D* '* 'mo 'e)u

Female/45 yo/ar!26AnamnesisShortness of breathDyspneu ) e(ort

'aro*ysma& 3o%turna&Dyspneu=rthopneu3auseaDiagnose) as i)neyfai&ureDiagnose) ashypertension"hysi#al

e$aminationH$S 4"6B' 210!0 mmg'R ? bpmRR 2 tpmDry sin J5nemia $onun%ti-a

K>' L R J 4 %m207/08

$or: i%tus $S > 2%mM$ SMurmur systo&i% gra)e/!6 at a&& -a&-eRhoni J!J;)ema J!JE=' "00 %%!12 hrLab %n!in&sb @,/ gr!)

Er!$r ?4,20!?,/@mg!)&eHFR 6

4.$hroni%Ci)neyDisease

stage "=nRoutineemo)ya&isis

4.1 3ephros%&erosis

4.2 3S5D

3ephropathy

=2 10 &pm -ia 3RBMSemifo+&er positionBe) rest3egati-e Iui) ba&an%e

"00 %%- p&ugRena& Diet 1?00%a&!)ay o+ sa&t 2g!)ay, 'rotein "0g!)ayFurosemi)e )rip 20mg!hour

'er =ra& :$&oni)ine / * 0,1" mgrbesartan 00/00 mg

emo)ia&ysis $ito

>S$omp&ainErine

pro)u%tionEreum$reatinin

F&ui)restri%tion,e*p&a

nationaboutrena&rep&a%ementthera

py

$E; 53D $E; ' D 'D ' 'M ' )


14/15

$E; 53D $E; ' D* 'D* '* 'Mo ' e)uFemale/45 yo/ar!26AnamnesisShortness of breathDiagnose) as i)neyfai&ure"hysi#al

e$aminationH$S 4"65nemia $onun%ti-aLab %n!in&sb @,/ gr!)M$> ?0,@0 IM$ 2?,/0 pg

". 5nemia

Re&ate)

$hroni%

Ci)ney

Disease

".1 5nemia

Def ;'=

".2 5nemia

)ef Fe

"./ 5nemia

)ef B12".4 5nemia

)ef asam

fo&at

B&oo)

Smear

Reti%u&o%yt

%ount

S, B$,

Saturation ransferin

'&an for

erytropoetin

$B$ Diseas

e,

%ause

of

anem,i

a,treatm

ent,

)iet,

%omp&i%

ation

Female/45 yo/ar!

26

RBS : 2@1 mg!)

6.

yperg&y%emia state

6.1 Stress

n)u%eyperg&i%emi%State

6.2Diabetes

Me&&itustype 2

Fasting

B&oo)H&u%ose2 our 'ost'an)ria&B&oo)H&u%ose

$onrm the

)iagnose) 7+aitfor the FBH an)2''BH8

FBH,

2''BH

$on)iti

on,treatment

Female/45 yo/ar!26AnamnesisShortness of breath"hysi#ale$aminationRhoni J!J;)ema J!J3atrium : 1// mmo&!

@.yponatremiahipoosmo&arhyper-o&emi%

@.1 >o&umeo-er&oa)

BK '&asma;&e%tro&yteurine

Furosemi)e asabo-e

S;post%orre%tion

Disease,treatment,%omp&i%ation


15/15

han 9ou

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