Emergency Case Report of CDL and CKD Malfunction

MALFUNCTION CDL AND CKD

Presented by “Vascular”

Supervisor : “dr. Ilham Arif, Sp.B. Subsp. BE (K)., M.Kes., FINACSS”

Emergency Case Report Mei 2024

Genereal Surgery Division Departement of Surgery University of Halu Oleo

Patient’s Identity

Name : Arjuddin Age : 47 y.o Gender : Male

Religion : Moeslim Occupation : Retired

Address : Unaaha Village Hospitalized : 19^th May 2024

Secondary Survey

Main Complaint:

Pain in the catheter double lumen (CDL) in the right neck

History Talking:

The patient came with complaints of pain and bleeding in the catheter double lumen (CDL) in the right neck, felt yesterdey after patient hemodailysis in Konawe’s Hospital. Other complaints include swelling of the testicles, after installing a urinary catheter a week ago. Patient not febris after hemodialysis and have had dialysis three times in the Konawe’s Hospital with schedule on Tuesday and Friday. CDL was installed in Bahteramas’s Hospital 10 days ago. The patient has history of hypertension.

Physical Examination

Generalist Status:

General condition : Moderate illness

Consciousness : E4V5M6 (Composmentis) Nutritional status : good

Vital Sign:

BP : 148/81 mmHg HR: 89x/minute RR: 22x/minute Temp : 36.7⁰C SpO2 : 97%

VAS : 3/10

Physical Examination

Present Status

 Head : normocephalic

 Eye : pupil isokor, Anemic conjunctiva (+/+), ikterik (-/-)

 Nose : rhinorrhea (-), epistaxis (-)

 Mouth: pallor (-), stomatitis (-), cyanosis (-)

 Ears : ottorhea (-)

 Neck : enlarged lymph nodes (-)

 Thorax: Symmetrical left and right, tenderness (-), mass (-), sonor (+/

+), vesicular breath sounds (+/+), wh (-/-), rh (-/-).

 Abdomen : follow breath, distended (-), peristalsis (+) normal impression, tenderness (-), tympanic (+)

 Upper estremities: warm acral, crt<2 sec.

 lower extremities : left (localized status), right (warm acral, crt<2 sec)

Physical Examination

Localized Status:

 Neck :

Inspection: CDL on the right neck (+), Bleeding (+), pus (-), eritema (-), hematom (-).

Palpation: Tenderness (-)

 Testicles :

Inspection: oedema (+), eritema (-) Palpation: Tenderness (-)

Laboratory test

Hematology: (19/05/2024)

Item Find Satuan Nilai rujukan

WBC 5.5 10^3/µL 4.-10

RBC 3.35 10^6/µL 4.0-6.0

PLT 217 10^3/µL 150 - 400

Hb 9.9 g/dl 12-16

HCT 27.8 % 37-48

MCV 83.0 fL 80-97

MCH 29.60 pg 26.5-33.5

Diagnosis

Working Diagnosis :

Malfunction CDL and CKD

Planning

― Replacement the Catheter Double

Lumen (CDL)

Thank You