Case Presentation

Patient’s identity

• Name: Ms. Kartini• Age: 19 years old• Sex: female• Occupation: waitress in a restaurant• Education: 3rd grade of elementary school• Status: single• Address: Kampung Melayu, Tangerang• Medical record number: 04715750

Chief complaint

• loss of consciousness since 1 hour before hospital admission

History of present illness• 4 months before hospital admission the patient

experienced excessive menstruation. The duration was 7 days, but the amount increased. She changed her pad 10 times a day, and was accompanied with pain. The pain was relief if there had been tissue flowing out of her vagina. The color was dark. About three days later, she got loss of consciousness 2 times. It occurred when she just woke up in the morning and at 11 a.m. when she wanted to go to the bathroom. However, the patient was not brought to the hospital either sought for any medical treatment. She was just given “jamu” by her mother. About a week later, the menstruation ceased and was followed with a vaginal discharge. Vaginal discharge was serous, only a little, itchy and smelly.

• 3 months before hospital admission, the patient experienced similar characteristic of menstruation; excessive in amount (changed 10 pads a day), accompanied with pain. Six days later, she was brought to a midwife and was given 3 kinds of drugs; green round tablets 3x1, white round tablets 3x1, Fe tablets 3x1, all were drunk for 3 days. Seven days later, the menstruation ceased, but was followed with a vaginal discharge. The characteristic of vaginal discharge was similar like before; serous, little, itchy, and smelly. During this menstrual period, the patient experienced headache and fatigue. Therefore, she just slept all day.

• 2 months before hospital admission, the patient still experienced the same complaint; excessive menstruation for 7 days, and was followed with vaginal discharge after that.

• 1 month before hospital admission, the patient was brought to Sitanala Hospital due to loss of consciousness and excessive menstruation. She was hospitalized for 7 days and was said to have bleeding problem and kidney disease. During hospitalization, she received blood transfusion for 4 packs. After that, she was referred to Tangerang general hospital. Here, she attended outpatient clinic once. She was prescribed 12 kinds of drugs and was ever scheduled to undergo hemodialysis, however the later was never done because the waiting list for hemodialysis was full.

• 18 days before hospital admission, the patient still experienced excessive bleeding which was followed with serous vaginal discharge, smelly, and itchy.

• 7 days before hospital admission, the physical condition worsened. She was very fatigue even when performing mild activities, shortness of breath (+) especially when having activity; when sleeping in supine position, so she needs 3 pillows; she also could not sleep well in the night due to shortness of breath. Cough (+), mucus (-), blood (-), fever (+) not measured, chill (+). She also admitted of having dry skin and never got sweat. Defecation once a day, the amount decreased, watery (-), blood (-). Urination decreased, pain when urination (+), blood (-).

• During sick, the patient has lost her body weight for about 12 kg. Eating and drinking are less.

Summary of history of present illness

History of Past Illness

• similar complaint before (-), hypertension (-), diabetes mellitus (-), allergy (+) of meat and fish, liver disease since 7 years old

History of Family Illness

• actually, the patient is not a biological child of her mother. Her biological parents died when she was baby. But her present families living with her do not have similar complaint like her.

Social History

• Patient works as a waitress in a restaurant for 2 years.

Obstetric History

• Menarche 17 years old, duration is 7 days, pain (-), changing pads 3-5 times a day, regular, 30 days cycle.

• She is not married yet.

Immunization History

• according to her mother, she was never given immunization before.

General ExaminationAlertness: somnolenBlood pressure: 100/70 mmHgHeart rate: 90 bpm, strong, regularRespiratory rate: 20 bpm, deep, regularTemperature: 36,50C

• Head : deformity (-)• Eye : anemic conjunctiva (+/+), icteric sclera (+/+)• Neck : JVP 5-0 cmH2O, lymph nodes are not palpable• Lung : P – sonor +/+• A – Vesicular +/+, Rh +/+, wh -/-• Cor : P – ictus cordis at one finger to the middle from mid clavicle line of 5th intercostals space

A – HS I-II normal; murmur (-), gallop (-)• Abdomen : flatted, liver and lien not palpable; Tenderness (-) • Extremities : warm acral; edema - - ; CRT 2’’

Laboratory Result(23rd December 2010)• SGOT/SGPT: 42(↑)/28• Glucose level: 90• Ur/Cr: 349(↑)/10.5(↑)(25th December 2010)• Blood Gas Analysis• pH – 7,337 (↓)• pCO – 234.9 (↓)• pO2 – 28.0 (↓)• HCO3 – 18.3• tCO2 – 19.4 • Electrolyte: Na/K/Cl 129.4/3.68/87

• (26th December 2010)• Hb: 4,6(↓)• Leukocyte: 9300• Ht: 40%• Platelet: 408,000

Working Diagnosis

• Encephalopathy uremicum• CKD stage V with acidosis metabolic, anemia,

hyperkalemia • Anemia gravis • CHF fc III • Hyponatremi hyperosmolar

Management

Diagnostic Plan• Check back blood gas analysis and electrolyte

post correction• Check back FBC post transfusion• Check HbsAg anti HCV

Therapy Plan• O2 3L nasal mask• Venflon• PRC transfusion 300cc/day• Lasix 2 x 2 amp• Folic acid tab 1x 3• B12 tab 3 x 1• CaCO3 3 x 1 tab• Bicnat 3 x 2 tab• NGT – diet 4 x 200 cc↓

menorrhagiamenorrhagiaCHF gr IIICHF gr III

Decreased Renal perfusion Decreased Renal perfusion

Decreased GFRDecreased GFR

CKD VCKD V

(140-19)x45x0.85/72x10,5= 6.12(140-19)x45x0.85/72x10,5= 6.12Ureum increasedUreum increased

Encephalopathy uremic

Encephalopathy uremic

Liver diseaseLiver disease

anemiaanemia

Hyponatremia hyperosmolarHyponatremia hyperosmolar

Increased cardiac work

Increased cardiac work

Thank you