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Supervisor:

Dr.Ninik Burhan Sp-PD

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SUMMARY OF DATA BASEMr Hamzah, male, 56yo.

CHIEF COMPLAINT : Shortness of breath

HISTORY OF PRESENT ILLNESS :- Patient presents with shortness of breath since 4 days

ago. Shortness Of Breath worsens with rest.

- Patient also complains of general weakness and

bodyache since 4 days ago.

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SUMMARY OF DATA BASEPatient also complains of cough since 1 week ago, with

small amounts of white sputum. Cough decreases withrest and increases upon lying down.

Nausea (-) Vomitting (-)Patient also complains of bilateral flank pain and leg

edema since 1 month ago.

Patient also complains of blurry vision since 4 months

ago.Patient poorly controlled Diabetes Mellitus since 10

years ago. Glibenclamide was prescibed but notroutinely taken. Never checked his RBS routinely

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SUMMARY OF DATA BASEPatient had hypertension. (remembers his blood

pressure was 140/90, but cant remember from when)

Patient routinely takes energy drinks (kratingdaeng,extrajoss, herbal potions)

History of past illness :

Patient has a history of untreated left inguinal herniasince 1991. Patient refuses surgical treatment.

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PHYSICAL EXAMINATIONGENERAL APPEREANCE LOOKED MODERATELY ILL

GCS : 456 NORMOWEIGHT BW 53kg BH 160 cmBP : 160/90 mmHg PR : 100 bpm RR : 18 tpm T ax : 36.3 C

HEAD ANEMIC (+) ICTERIC (-)

NECK JVP R + 6 cm 30

THORAX COR ICTUS : INVISIBLE , PALPABLE AT ICS V MCL SRHM : SL D LHM : ICTUS MCL S ICS VS1 S2 SINGLE MURMUR (-)

LUNG SIMETRISFS D=S

v vv v

v v

Rh : - -+ +

+ +

Wh : - -- -

- -ABDOMEN SIMETRIS FLAT

BS + (N)LIVER SPAN 10 cm TRAUBES SPACE thympani

EXTREMITAS EDEMA -/- Cold acral

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LABORATORY FINDINGLAB VALUE LAB VALUE

Leucocyte 12.120 3.500-10.000/L Natrium 129 136-145 mmol / L

Haemoglobin 7.6 11,0-16,5 g/dl Kalium 5.28 3,5-5,0 mmol / L

PCV 21.90% 35-50% Chlorida 98 98-106 mmol / L

Trombocyte 443.000 150.000-390.000/L Albumin 2.90 3.5-5.5 g/dL

MCV 83.6 80-97 osm 272 2 (na+k) + rbs/18

MCH 29 26,5 - 33,5 RBS 75

SGOT 16 11-41 U/L

SGPT 15 10-41U/L

Ureum 248.50 10-50 mg/dL

Creatinin 14.55 0,7-1,5 mg/dL

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BLOOD GAS ANALYSALab Value

BGA O2 4 L/mnt NC

PH 7.44 7,35-7,45

PCO2 25.4 35-45

PO2 73.3 80-100

HCO3 17.2 21-28

O2 saturation 95.4 >95

Base Excess -7.2 -3 until +3

Conclusion Acidosis metabolic fullycompensated

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ECG

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ECGECG :Sinus Rhythm 98 bpm

Frontal Axis : normal

Horisontal Axis : normalPR interval : 0.12

QRS complex :0.04'

QT interval :0.28Conclusion : Sinus rhythm HR 98

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CXR

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CXR AP position, KV enough, asymmetric, less

inspiration

Trachea in the middle,

Bone N and soft tissue N,

Phrenico costalis angle on Right and Left sharp.

Hemidiaphragma D/S dome shaped.

Pulmo : butterfly appearance of lung, enlarged hillus Cor: site normal (CTR >50%)

Conclusion : looks like cardiomegaly from AP positionand ALO due to butterfly appearance

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CUE AND CLUE P List INITIAL DIAGNOSE PDx PLANNING THERAPY PMo

Male, 56 yo

General weakness

Shortness of breath

Leg swelling

Uremic skinRonchi in lung

Diabetes Mellitus

uncontrolled

History of energy drinks

HT 160/90mmHg

Anemia Hb 7.3g/dl

MCV/MCH

Normo-normo

Ur/cr 248.50/14.55

eGFR 4.4

K 5.28

1. CKD

st 5

1.1 DM

nephropathy

1.2 Hypertension

nephrosclerosis1.3 GNC

Usg

abdomen

02 2-4 lpm

Kidney diet 1900

kcal/day

Low salt < 2 gr/day

Protein diet 0,6-0,8

gr/kgbw/day

Inj furosemide

40400 mg

Kalytake 2 x 1 sach

Renal replacement

therapy(Hemodialisa)

Ureum

Creatin

in,

Urineproduc

tion

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CUE AND CLUE P List INITIAL

DIAGNOSE

PDx PLANNING THERAPY PMo

Male, 56 yo

Shortness of breath

Leg swelling

History of DM

History of high blood pressureBlurry vision

HT 160/90mmHg

Anemia Hb 7.3

Ur/cr 248.50/14.55

2. HT st

II

2.1 Primary

hypertension

2.2 Secondary

hypertension

USG

Abdomen

Inj, Furosemide

40mg-40mg-0

Po Clonidine 3 x

0.15mg

Subj.

BP

CUE AND CLUE P Li t INITIAL PD PLANNING PM

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CUE AND CLUE P List INITIAL

DIAGNOSE

PDx PLANNING

THERAPY

PMo

Male, 56 yo

General weakness

Anemia normochrom

Normositer = 7.3

MCV/MCH

3.

Anemia

Normoch

romeNormocy

ter

3.1 EPO

deficiency

3.2 Chronic

Disease

Blood

smear

Reticulocyt

count, DL

Bed rest

Improve diet

Consider PRC

transfusion

Subjective,

Monitor Hb

CUE AND CLUE P Li t INITIAL PD PLANNING THERAPY PM

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CUE AND CLUE P List INITIAL

DIAGNOSE

PDx PLANNING THERAPY PMo

Male, 56 yo,

General weakness,

SOB,

History of DM/HT

Leg edemaHT 160/90

Anemia Hb 7.3

Ur/Cr 248.50/14,55

Albumin 2.90

4.

Hypoalbu

minemia

4.1 Renal loss

4.2 Low intake

- High protein diet.

Treatment for CKDSubjec

tive

VS,

urineprod,

edema.

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THANK YOU