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CASE REPORTA 58 YEARS OLD MAN WITH STAGE V CHRONIC KIDNEY DISEASE, STAGE II
HYPERTENSION, AND NORMOCHROMIC NORMOCYTIC ANEMIA
GESTANA ANDRU
G6A 009 077
Dr. DWI LESTARI Sp.PD KGH
IDENTITY
• Name : Mr. M• Age : 58 yo• Sex : Male• Education : Elementary graduated• Occipetion : Unemployment• Address : Menganti, Jepara• Admission Date : March 24 2011• Reg No : 6575182
DAFTAR MASALAH
NO ACTIVE PROBLEMS DATE NO PASSIVE PROBLEM
DATE
1
2
3
Stage V Chronic kidney Disease with Hyperkalemia
Stage II Hypertension with LVH
Normochromic Normocytic Anemia
25/03/2011
25/03/2011
25/03/2011
ANAMNESIS March 25 2011 at C3C ward
• Chief Complaint: Weakness
12 days agoWeakness (+), gradually, all day long, daily activity
disabled
OTHER SYMPTOMS
Positives Negatives
1. Dizziness2. Tiredness3. Loss of appetites4. Palpitation5. Swollen leg6. Less micturition (1,5
glass/day)
1. Fever2. Blurred vision3. Cough and influenza4. Epistaxis5. Vomiting6. Gastric pain7. Cachexia8. Low back pain9. Painful micturition
ANAMNESIS March 25 2011 at C3C ward
• Chief Complaint: Weakness
RSDK
12 days agoWeakness (+), gradually, all day long, daily activity
disabled
10 days at RS KartiniBlood lab, Chest X-ray
Ultrasound
2 days agoHD neededPatient was
reffered
MEDICAL HISTORY
• History of hypertension for 18 years, uncontrolled, medication taken but the patients couldn’t recall it
• History of diabetes, asthma, heart disease, lung disease was denied
• History of black “tarry” feces about a month ago• History of fever and accompanied by painful and
frequent urinating was denied
Family History• History of similar symptoms and signs was denied• History of diabetes, hypertension, heart disease was
denied
Socioeconomic Profile• Low economic state
PHYSICAL EXAMINATION (MARCH 25 2011)
• General condition: severely ill• GCS : E4M6V5 : 15
VS:
BP: 160/100 mmHgPulse: 82 x/minRR: 20 x/minTemp: 37oC
Anthropometry assessmentBW: 55 kgs Height: 1.60 m
BMI: 21.48 (normoweight)
Paleness of conjunctival
palpebra (+/+), oedema (-/-)
ENT: discharge (-)
JVP N, nodes enlargement (-),
deviation of trachea (-)
COR:I: ictus cordis not visible
Pal: IC was palpated on the VIth ICS, 2cm lateral from left midclav line, widened beat (-), finger lifting(+), thrill (-), sternal lift (-), left parasternal pulsation (-), epigastrial pulsation (-)
Per:heart configuration•Upper: 2nd ICS left parasternal line•Right: 2nd ICS right parasternal line•Left: Vith ICS 2cm lateral to left midclav line•Base of the heart flattened
•Aus: HR: 60 beats/min, holosystolic murmur (+) grade 2/6 on apex cordis to the axilla
LUNGS EXAM, Anterior and Posterior Aspects
•Ins: lungs expansion was symetricRate and pattern was normal
•Pal: lungs expansion was symetric, tactile fremitus was symetric
•Per: Resonant in all area of the lungs
•Aus: Breath sounds :vesicular on the both sides of lungs, no ronchi, wheezes, or rales were found
Abdomen
• Ins: the abdomen was distended
•Aus: bruits (-), loss of bowel sounds (-), hyperactive sounds (-)
•Per: liver size normal, shifting dullness (-)
•Pal: hepatosplenomegaly was not found, tenderness (-)
Extremity:
Cyanosis (-)
Oedema (-)
Capp Refill <2’’
LABORATORY FINDINGSHaematology Normal
Range23/03/11
RS KartiniNormal Range
24/03/11RSDK
25/03/11RSDK
Hb (g%)Ht (%)RBC(10 6 /mm3)MCV (fl)MCH (pg)MCHC (g/dl)WBC(10 3 /mm3)Platelets(10 3 /mm3)
14 – 1840 - 48
(-)
(-)(-)(-)
5 – 10
150 – 400
7.120.4(-)
(-)(-)(-)8.7
270
13 – 1640 – 54
4.5 – 6.5
76 – 9626 – 3229 – 364 – 11
150 – 400
8.3024.52.90
84.4028.5033.807.20
224.0
9.0026.63.16
84.2028.4033.706.80
222.0
Findings: Anemia Normocythic Normochromic Anemia
Normocythic Normochromic Anemia
NormalRange
22/03/2011RS Kartini
NormalRange
23/3/2011RS Kartini
BGL (mg/dl)Ureum (mg/dl)Creatinin (mg/dl)AlbuminNa+ (mmol/l)K+ (mmol/l)Cl- (mmol/l)Ca (mmol/l)
80 - 15010 - 50
0.8 – 1.2
136 - 1464.4 – 4.8
8.1 – 10.4
136297.2
10.2-
1367.1-
9.6
Bilirubin totBilirubin dirSGOTSGPTGamma GTALPBlood type
0 - 10 – 0.2515 -389 – 4211 – 61
64 – 644
0.590.15343628
191B Rh (+)
Findings AzotemiaHyperkalemia
CREATININ CLEARANCE TIMECockcroft-Gault Formula
• CCT : (140-age) x Body weight
72 x Creatinine• (140 – 58) x 55 = 6.14 ml/minutes/1,73m2
72 x 10.2
• Imunology (March 23 2011)• HbsAg (-)
ABDOMINAL ULTRASOUND (03/21/2011)Findings : Chronic process on both kidney with
contracted kidney
ECG Dat Emergency Ward(24/03/2011)
Rythm : sinus, HR : 51 x/minute, Axis: normoaxis Trantition zone: at lead V3, V4
P wave : 0,08 s, Pulmonal P wave (-), Mitral P wave (-), PR Interval:0,18s QRS wave : 0,12 s, Q Patologic wave (-), T wave: tall T wave (-), inverted T wave (-)Segment ST: isoelektric, SV1 + RV5/V6 >35, R/S <1,
Findings: Sinus Bradychardia with LVH
RESUME• A 58 yo male patient came to the emergency ward of RSDK with chief
complaint: weakness, patient needed help to conduct daily activities. Patient was reffered from RS Kartini, and had been treated for 10 days,
blood lab, ultrasound, and chest X ray was conducted and the results showed chronic kidney disease and hemodialysis was needed, and the
patient was reffered to RSDK.
• Dizziness (+), fatigue (+), nausea (+), palpitation (+), loss of appetite (+), dyspneu (+), swollen legs (+), lessening micturition (+)
• On physical examination, the patient was severely ill, vital signs : BP: 160/100 mmHg, RR 20 x/min, pulse 82 x/min, BMI was normoweight
• Further exam showed the left ventricle hypertrophy with sholoystolic murmur grade 2/6 on the apex to axilla, no anomalies in the lungs, abdominal exam showed no abnormalities, kidney ballotement (-),
edema was found in the inferior extremities.
• Laboratory findings showed normochytic normochromic anemia, azotemia, and hyperkalemia
• Ultrasound showed chronic process on both kidney with contracted kidney
• Electrocardiography showed sinus bradychardia, left ventricle hypertrophy
LIST OF ABNORMALITIES• Weakness -Dizziness• Fatigue -Nausea
Palpitation -Dyspneu• Loss of appetite -Lessened micturition• History of melena -Hitory of 18 years with hypertension• BP160/100 mmHg -Paleness of conjungtival palpebrae• Dryness, Paleness of buccal mucosa• Ictus cordis was palpated on Vith ICS 2 cm lateral from ileft midclav line• Systolic murmur grade 2/6 on apex to axilla• Oedema on inferior extremity -Hb: 9.00 gr%• Erithrocyte: 3.16 jt/mm3 -Ureum: 297.2 mg/dl• Creatinine: 10.2 mg/dl -Hyperkalemia• CCT 6.14 ml/menit/1.73 m2
• Ultfrasound: Chronic process on both kidney with contracted kidney• ECG: Left ventricle hypertrophy
PROBLEMS
1. Stage V CKD with hyperkalemia
2. Stage II Hypertension with LVH
3. Normochromic Normocytic Anemia
INITIAL PLAN• Problem 1. CKD Stage V with Hyperkalemia• Ass : - Determining etiology:- Nefropatic Hypertension • - Primary Glomerulonephrytis• - Detremining bleeding complication• IP • Dx : Urinalysis, uric acid, PPT/PTTK, feces analysis, kidney biopsy• Rx : - RL infusion drip 12 dpm
• Ca Gluconas Inj 1 vial• - Kalitake tablet 3x1
• - Kidney replacement therapy with hemodialysis• - uremic soft food diet 30 g of proteins, low salt 1900 cal
• Mx : ureum serum,creatinine serum, , electrolyte, fluid balance
• Motivate to patient to measure urinary output and maintain the fluid taken according to the urine
• Motivate the patient and family not to take any other food beside what the hospital gave him
• Motivate the patient and family to follow the schedule of hemodialysis
Problem 2. Hypertension Stage II with LVH
Ass : Determining risk factor and target organ complication (hypertensive retinopathy, hypertensive neuropathy, hypertensive nephropathy, Ischaemic Heart Disease)
IP Dx : Blood Glucose, Lipid Profile, Funduscophy, EMG, ECGRx : - Valsartan 1 x 80 mg
- Diltiazem 3x60 mg
- Low Salt dietMx : KU,TVEx : -Motivate the patient to maintain the medication taken and low salt diet,
avoid stress, and regular check up for the target organ impairment
• Problem 3 : Normochromic Normocytic Anemia• Ass : - chronic disease• - bleeding• - iron deficiency• IP• Dx : Blood cell morphology, reticulocythe, TIBC, ferritin
serum, transferrin serum• Rx : PRC transfusion 1 pack with 1 vial lasix injection• Mx : Vital signs, Hb serials• Ex : -
THANK YOU