pomr acute lung oedema with chronic renal disease

ALO CKD

1. Summary of Database Mrs. S / 65 yo/ RHCU Ciliwung Autoanamnesis Chief Complaint : Shortness of Breath History of Present Illness : Shortness of breath has been intermittent especially since the last 1 week, improving after resting and receiving oxygen. Feels weak with a little more activity than usual. Sleeps more comfortably with 2-3 pillows. Awakening due to shortness of breath is denied. Fever (-) Cough with phlegm (+) is felt since 1 week ago, but the phlegm feels unable to come out. Abdominal bloating and fullness were experienced by the patient since 1 day before admission.. Complaints make the patient uncomfortable and difficult to sleep. The body feels weak since the last 2 days so that the patient is difficult to walk alone if not helped by being carried by others. Nausea has been felt since 2 weeks and has disappeared. Vomiting (-). Appetite is still quite good, the patient can finish 1 small portion of porridge per meal. Difficulty in defecation is felt by the patient especially since 2 weeks ago. The stool that comes out is only small and hard. Has received microlac 2x but only comes out a little. Stomach feels slightly enlarged and full. Diagnosed with CKD since December 2021 and routinely hemodialysis since December 31, 2021. Patients routinely dialysis 2x a week every Monday and Thursday at RSSA, with Double lumen access. Post installation of AV shunt since 2 months ago in the right hand. Diagnosed with HT and DM since 11 years ago. The patient routinely takes Lisinopril 1x10 mg, Adalat Oros 1x30 mg, SF 2x1, SC Lantus 0-0-12 IU. The patient admitted to taking amlodipine 1x10mg.

2. Summary of Database Past Medical History: Diagnosed with CKD since December 2021 and routinely hemodialysis since December 31, 2021. Patients routinely dialysis 2x a week every Monday and Thursday at RSSA, with Double lumen access. Post installation of AV shunt since 2 months ago in the right hand. Diagnosed with HT and DM since 11 years ago. The patient routinely takes Lisinopril 1x10 mg, Adalat Oros 1x30 mg, SF 2x1, SC Lantus 0-0-12 IU. The patient admitted to taking amlodipine 1x10mg. Family History: - No family history of high blood pressure, no family history of kidney failure. Social History: The patient is a housewife and lives with her niece Review of System: Shortness of breath (+), cough, nausea (+), abdominal bloating(+)

3. Physical Examination General appearance: looked moderatel y ill GCS 456 UOP anuria SpO 2 99% N C 4 lpm BW : 48 kg BH : 15 3 cm BMI : 19,6 (normoweight) RBS: 155 mg/Dl BP 154/56 mmHg HR   47 bpm RR 2 2-24 x/min T   36,8 o C Head Anemic conjunctiva (+) , icteric sclera (-), lymphnode enlargement (-), double lumen in r. subclavia dextra , pus (-) Pupil isokor, 3mm/3mm, RCL +/+, RCTL +/+ Thorax Symmetrical, retraction (-) Pulmo Sonor | Sonor Vesicular | Vesicular Rhonchi: + | + Wheezing: -/- Sonor | Sonor Vesicular | Vesicular + | + -/- Sonor | Sonor Vesicular | Vesicular + | + -/- Cor Ictus cordis palpable 2cm lateral ics vi S1 S2 single, regular, gallop (-), murmur ( - ) Abdomen Rounded , soefl, bowel soun d slightly increased , no organomegaly Extremities Warm, dry, red acral, CRT < 2 s, edema +/+ slightly

4. Laboratory Findings (14/7/24) LAB VALUE NORMAL LAB VALUE NORMAL Leukocyte 12.590 4.700 – 11.300 /µL Ureum 91,4 20-40 mg/dL Hemoglobin 10 11,4 - 15,1 g/dl Creatinine 7,82 <1,2 mg/dL PCV 30.6 38 - 42% eGFR 4,192 Thrombocyte 90.000 142.000 – 424.000 /µL Sodium 1 20 136-145 mmol/L MCV 82,2 80-93 fl Potassium 4,8 3,5-5,0 mmol/L MCH 30,3 27-31 pg Chloride 87 98-106 mmol/L Eo/Bas/Neu/ Limf/Mon 5.9/ 0.3/ 78.7/ 6.4/ 8.7 0-4/0-1/51-67/ 25-33/2-5 CRP 0,31 < 0,3 HbsAg NR AntiHCV HbA1c NR 6.4%

5. Blood Gas Analysis (14/07/2024) Room Air Normal pH 7. 52 7.35-7.45 pCO 2 28,9 35 – 45 mmHg pO 2 112,4 80 – 100 mmHg HCO 3 2 3,9 21 – 28 m mol/L O 2 saturation 97, 9 % > 95 % BE 0,9 (-3) - (+3) m mol/L Conclusion: respiratorik alkalosis uncompensated P/F ratio : 339 mmHg (Not ARDS)

6. Electrocardiogram (14/07/2024)

7. Electrocardiogram (14/7/24) Junctional rhythm, bradicard ia HR 46 bpm Frontal Axis Horizontal Axis P Wave PR interval QRS complex QT interval ST Segment T Wave : Normal : CWR : not present : 0.16” : 0.08” : 0.32” : normal : normal, U wave Conclusion : Junctional bradicardia, HR 46 bpm, LAD, CW, U wave

8. Chest X-ray (14/7/2024)

9. Chest X-ray (14/7/2024) AP position, enough KV, less i nspiration, rotational position Soft tissue was normal, skeleton was intact Trachea was in the middle, L eft costophrenic angles were sharp, there was opacity in the right hemithorax covering the right costophrenicus angle. Pulmo : Increased vascular pattern with perivascular infiltrates. Cor : Normal shape, size and position There is a double lumen through the projection of the right subclavian vein with the distal end as high as the T10 vertebrae Conclusion: Interstitial type pulmonary edema. Minimal right pleural effusion

10. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S/ 65 yo/ Ciliwung Subjective Shortness of breath since 1 weeks before admission Cough with phlegm since 1 weeks Diagnosed with CKD since December 2021 Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm Cor: IC palpable 2cm lateral MCL S Pulmo: Ves +/+ Rh +++/+++ Wh -/- Ext : Edema slightly inferior +/+ ECG 14/7/24 Junctional bradicardia, HR 46 bpm, LAD, CW, U wave CXR 14/7/24 Interstitial type pulmonary edema. Minimal right pleural effusion 1. Acute Lung Edema 1.1 Cardiogenic dt. ADHF Wet Warm pf bradicardia 1.2 Non Cardiogenic dt Pleura Efusion D Non-pharmacology: Bed Rest Semifowler O 2 NC 4 lpm Negative Fluid Balance HD CITO Pharmacology: IV Furosemide 3x40mg PO Captopril 3x25mg Pmo: S, VS, Spo2, fluid balance Pedu: Educate about her condition may related to inadequate hemodialysis or because low heart rate and hemodialysis will performed to treat the shortness of breath

11. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective - Diagnosed with CKD since December 2021. Routinely dialysis 2x a week every Monday and Thursday with Double lumen access. - Diagnosed with HT and DM since 11 years ago. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg UOP : anuria Conjuntiva anemis , double lumen di r. subclavia dextra ECG 14/7/24 Junctional bradicardia, HR 46 bpm, LAD, CW, U wave Lab 14/7/24 Hb : 10 RBS : 155 mg/dL Hba1c : 6.4% Ur/Cr: 91.4/ 7.82 eGFR: 4.195 2. CKD stage 5 on routine HD 1.1 HTN 1.2 DKD - Renal biopsy Non Pharmacotherapy - Hemodialysis as scheduled 2x/weeks - Renal diet 1700 kcal / day, protein 1-1.2 gr / day, low salt < 2 gr / day Pharmacotherapy - PMo : Subjective, Vital sign UOP, Overload condition Uremic sign, Renal emergency PEdu: -Explain about Chronic Kidney Disease, the possibles causes of it and the urge to therapy. Also the therapy is need for routine dialysis as her renal replacement therapy.

12. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective Shortness of breath since 1 weeks before admission Diagnosed with HT and DM since 11 years ago. The patient routinely takes Lisinopril 1x10 mg, Adalat Oros 1x30 mg, SF 2x1, SC Lantus 0-0-12 IU. The patient admitted to taking amlodipine 1x10mg. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm Cor: IC palpable 2cm lateral MCL S Pulmo: Ves +/+ Rh +++/+++ Wh -/- Ext : Edema slightly inferior +/+ ECG 14/7/24 Junctional bradicardia, HR 46 bpm, LAD, CW, U wave Lab 14/7/24 Na : 120 Osmolarity : 264 3. Symptomatic bracycardia 3.1 drug induced (CCB) 3.2 Electrolyte imbalance 3.3 Hypothyroid - TSH, FT4 - Echocardiography Non Pharmacotherapy Treat Underlying Causes Consult cardiology department considering transcutaneus pacing insertion if no improvement after electrolyte correction Pharmacotherapy IV Sulfas atropine 1mg (admission 1mg in emergency room) -> repeated every 5 minutes max 3mg PMo : Subjective, Vital sign, ECG evaluation PEdu: -Explain about the possible causes of Bradycardia can be a normal variation in some individuals but can indicate underlying issues and still needed to search for possible causes.

13. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S/ 65 yo/ Ciliwung Subjective Shortness of breath since 1 weeks before admission. Sleeps more comfortably with 2-3 pillows. Diagnosed with CKD since December 2021 Diagnosed with HT since 11 years ago Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm Cor: IC palpable 2cm lateral MCL S Pulmo: Ves +/+ Rh +++/+++ Wh -/- Ext : Edema slightly inferior +/+ EKG 14/7/24 Sinus Bradikardia HR 46 bpm, LAD, CW, U wave CXR 14/7/24 Interstitial type pulmonary edema. Minimal right pleural effusion 4. HF stage C FC III 4.1 HHD 4.2 CRS type IV Echocardiography Non-pharmacology: Bed Rest Semifowler O 2 NC 4 lpm Negative Fluid Balance Pharmacology: IV Furosemide 3x40mg PO Captopil 3x25mg Pmo: Subjective, Vital Sign, UOP,fluid balance, overload sign PEd: - Explain about the disease and the factor that can worsening the condition - Educate to restrict salt and water intake, avoid heavy physical activity and when neede to take the patient immediately to hospital (if shortness of breath worsens and the patient have difficulty of breathing)

14. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S/ 65 yo/ Ciliwung Subjective - Diagnosed with CKD since December 2021. Routinely dialysis 2x a week every Monday and Thursday with Double lumen access. - Feels weak with a little more activity than usual. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm UOP : anuria Conjuntiva anemis Lab 14/7/24 Hb : 10 MCV/MCH : 82.2/30.3 5. Anemia Renal 5.1 EPO Deficiency 5.2 Reduced Erythrocyte Survival 5.3 Fe Deficiency - SI, TIBC, Sat Transferin, Ferritin Non Pharmacotherapy -High Fe Diet Pharmacotherapy - Give eritropoeitin if the patient have no absolut anemia deficiency Fe with dose 80-150 IU/kgBB/week Pmo: S, VS, O2 hunger sign PEd: - Explain the patient that she has an anemia and the condition of anemia can caused by the Chronic kidney disease -Educate the patient and family to increase consumption of food with high Fe diet

15. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective - Diagnosed with CKD since December 2021. Routinely dialysis 2x a week every Monday and Thursday with Double lumen access. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm UOP : anuria Lab 14/7/24 Na : 120 Osmolarity : 264 6. Hyponatremia hypoosmolar hypervolemia dt dilutional - - Non Pharmacotherapy Fluid Restriction Pharmacotherapy - IV Plug - IV Furosemide 3x40mg Pmo: S, VS, Electrolyte serum, Seizure, GCS, fluid balance PEd: - Explain the patient that she has hyponatremia and may related to her disease and need to restrict fluid intake

16. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S/ 65 yo/ Ciliwung Subjective -Diagnosed with HT since 11 years ago.The patient routinely takes Lisinopril 1x10 mg, Adalat Oros 1x30 mg. The patient admitted to taking amlodipine 1x10mg. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg EKG 14/7/24 Junctional bradicardia , HR 46 bpm, LAD, CW, U wave 7. HT Stage 1 - - Non Pharmacotherapy -R enal diet 1700 kcal / day, protein 1-1.2 gr / day, sodium < 2 gr / day Pharmacotherapy - PO Captopril 3x25 mg PMo: S, VS (BP) PEd: Explain the patient about the Hypertension, Educate to change life style like consume low sodium diet, routinely exercise and take medications.

17. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective - Diagnosed with DM since 11 years ago. The patient routinely using SC Lantus 0-0-12 IU Objective BW 48 kg | BH 153 cm | BMI : 19,6 kg/m2 (normoweight) Lab 14/7/24 RBS : 155 mg/dL Hba1c : 6.4% 8. DM type 2 - - Non Pharmacotherapy - DIet DM 1700kkal/day Pharmacotherapy - SC Insulin Lantus 0-0-10 unit PMo : Subjective, Vital sign FBG, 2hPPBG PEdu: -Explain about the Diabetes mellitus and its complication Educate to change life style like consume low sodium diet, routinely exercise and take medications routinely

18. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective - Diagnosed with CKD since December 2021. Routinely dialysis 2x a week every Monday and Thursday with Double lumen access. Objective GA: Looked moderately ill, GCS: 456 BP : 154/56 mmHg I HR: 47 x/m RR : 22-24 tpm I Sat O2 : 99% on NC 4 lpm Lab 14/7/24 CBC: 10/ 12.590/ 30.60/ 90.000 9. Thrombocytopenia 9.1 Heparin Induced Trombositopenia 9.2 platelet dysfunction related to chronic kidney disease - Non Pharmacotherapy -Bedrest, avoid heavy activity Pharmacotherapy Treat underlying causes Free heparin hemodialysis PMo : Subjective, Vital sign, bleeding sign, CBC PEdu: -Explain about the possible causes of thrombocytopenia and avoid heavy activity and report any unusual bleeding or bruising.

19. POMR (Problem Oriented Medical Record) CUE AND CLUE PL IDx PDx PTx PMo&Ed Mrs. S / 65 yo/ Ciliwung Subjective - Abdominal bloating and fullness were experienced by the patient since 1 day before admission. F latus (+) - Difficulty in defecation is felt by the patient especially since 2 weeks ago. The stool that comes out is only small and hard. Has received microlac 2x but only comes out a little. Stomach feels slightly enlarged and full. L ast defecation 2 days ago Objective GA: Looked moderately ill, GCS: 456 Abd: round, BU (+) slightly elevated, traube tympanic space, dull shift (-) 10. Constipation - - Non Pharmacotherapy -High fiber diet Pharmacotherapy - PO Lactulose 3x1C - Dulcolac supp prn PMo : Subjective, defecation pattern PEdu: -Explain about the causes of constipation - Educate to change life style like consume high fiber diet, lifestyle modification and regular exercise

20. Problem Analysis CKD St 5 Anemia Hypertension Decrease EPO Production Shortened RBC survival True Iron Deficiency Bone marrow suppression Acute Lung Edema Heart Failure Increase cardiac workload Increase venous return RAAS GFR decrease Abnormality electrolyte Urine output decrease Uremic toxin increase Cytokine clearance decrease DM Type 2 Bradicardia CCB induced Electrolyte imbalance hypothyroid Thrombocytopenia HD

21. PROBLEM THEORY FACTUAL Hypertension Risk Factor of Hypertension Family History Advanced age Gender related risk pattern Lack of physical activity Poor diet, too much salt Overweight and obesity Too much alcohol Possible contributing factors : Stress Smoking and second hand smoke Sleep Apnea American Heart Association Poor Diet, too much salt Lack of physical activity Advanced age Risk Factors Analysis

22. Problem Theory Patient CKD st 5 Renal Replacement Terapy targeting BP ≤140/90 mm Hg if no proteinuria 2. targeting BP ≤130/80 mm Hg if proteinuria Avoiding high protein intake (>1.3 g/ kg/day) in adults with CKD at risk of progression. lowering salt intake to <2 gram per day of sodium ( corresponding of 5g salt) source papdi Slow down the disease progression Renal Diet 1700kCal/ day, Low salt diet<2g/day HD electif Prevent and treatment of cardiovascular disease Key Message Management

23. Risk Factor Analysis Problem Theory Patient Anemia Normochrome Normocyter Renal Disease From : Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low-and middle-income countries. Annals of the new York Academy of Sciences. 2019 Aug;1450(1):15.

24. Key Message Diagnosis

25. Key Message Pathophysiology From : Schefold JC, Filippatos G, Hasenfuss G, Anker SD, Von Haehling S. Heart failure and kidney dysfunction: epidemiology, mechanisms and management. Nature reviews Nephrology. 2016 Oct;12(10):610-23.

26. Key Message Pathophysiology From : Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron deficiency in chronic kidney disease: updates on pathophysiology, diagnosis, and treatment. Journal of the American Society of Nephrology. 2020 Mar 1;31(3):456-68

27. Key Message Management From : de Boer IH, Caramori ML, Chan JC, Heerspink HJ, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T. KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney international. 2020 Oct 1;98(4):S1-15.

28. Key Message Management KDIGO. 2012. Clinical Practice Guideline for Anemia in Chronic Kidney Disease

29. Key Message Management KDIGO. 2012. Clinical Practice Guideline for Anemia in Chronic Kidney Disease

30. Key Message Social Patient with ALO, CKD, and Hypertension must be educated for the compliance of the drugs Good emotional support from the family, health care provider, and spiritual support must be given to the patient Personal hygiene should be educated to the patient and family around him/her, and should always using face mask

31. Prognosis Ad Vitam : dubia ad bonam Ad functionam : dubia ad malam Ad sanationam : dubia ad malam