AKI ET CAUSA GASTROENTERITIS ACUTE AND DM TYPE 2

Identity

Name Age Gender Adress Occupation Religion Marital status Race Education

: Mr.E : 47 years : Men : Bambu Duri,Karawang : Farmer : Islam : Married : Sundanese : Junior high school

anamnese

Autoanamnese on 20th november 2012 from Rengasdengklok Ward

CLINICAL HISTORY

Main Complaint: Diarrhea since 4 days before admitted to hospital Additional complaint: Nausea, Vomitting, Headache, abdominal pain

History of Present illnes

Patient came to emergency unit RSUD Karawang with complaint that he had diarrhea more than 10 times/day since 4 days before admitted to the hospital. The diarrhea stool were not bloody, yellow coloured,and watery diarrhea. Patient didnt have fever Patient said that urination had decrease volume, yellow like tea coloured urin

History of Present Illnes

Patient also complaint have nausea, vomiting several times a day before admitted to the hospital, headache, abdominal pain, decrease body weight 2 kg in 4 days and lost of appetite

History of Past illnes

Same disease (-) Hypertention (-) Heart disease (-) Liver disease (-) Kidney disease (-) Urinary stones (-) Allergy (-) DM (-) Are all denied by the patient

Family History
DM (+)
Hypertention ()

No one in his family got a symptom like him

Heart disease ()

Allergy (-)

Liver disease (-) Kidney disease (-)

Asthma (-)

Lung disease (-)

Habit History

Smoking since junior high school 1 pack/day Alcohol (-) Tatoo (-) Drugs (-)

Physical Examination
Appereance : moderate ill
Conciusness : compos mentis Nutririon : Weight : 49 Kg Height : 165 cm BMI : 17,9 (Underweight)

Vital sign

Blood Pressure : 100/70

Heart Rate: 84x/min

Respiration Rate : 18x/min

Temperature : 36,5

Physical Examination

Head

Normochepaly, black hair, good distribution Anemic conjungtiva -/-, Icteric sclera -/Hiperemic (-/-), tenderness (-/-), secret (-/-) Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-) Red lip (+) dry (+). Carries (+) on M1-2 left and right. Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N) Lymph node: enlargement (-), tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O

Eyes

Ears

Nose

Mouth

Neck

Physical Examination
THORAX

INSPECTION
PALPATION

Ictus cordis is invisible

Ictus cordis is palpable at 5th ICS LMCS Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS Regular I - II absence of murmurs and gallop in hearts sound

PERCUTION

AUSCULTATION

Physical Examination

LUNG Inspection Palpation Percussion Auscultation

: Symmetrical : Equal vocal resonance : Sonor in both lungs : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)

Physical Examination
ABDOMEN Inspection : flat, symmetric, caput medusa (-), smiling umbilicus (-)

Palpation : Tenderness (+) Epigastrium pain (+) Distension (-) no liver and spleen enlargement murphy sign (-)

Percussion : tympanic pain present on abdominal percussion

Auscultation : bowel sound (+) 10 times/min , arterial bruit (-), venous hum (-)

Physical Examination

Warm acral

+ +

+ +

Oedem

+ +

+ +

Laboratory Findings 19 th october

Hematology

value 17 g% 9300/ul 323.000 54

Normal value 12-17 g% 5000-10.000 ul 150-450 ribu 37-48%

Hb leukocyte trombocyte Ht

DIFFERENTIAL count
Blood chemistry

0/0/0/82/16/2

0-1/1-3/2-6/40-70/2040/2-8

Random blood glucose

Ureum Creatinine

237 mg/dl
135,0 1,72

80-140 mg/dl
10-45 mg/dl 0,4-1,5 mg/dl

Laboratory Findings 20th october

Blood Chemistry Ureum
creatinine

Value 90,8 mg/dl

1,22 mg/dl

Normal Value 10-45 mg/dl

0,4-1,5 mg/dl

RESUME

symptom

Sign

Lab and Others

Diarrhea since 4 days ago more than 10 times a day Vomiting several times a day Abdominal pain

Blood pressure 100/70 mmHg Dry mouth (+) Epigastric pain Bowel sound 10 times/min

Ureum 135 mg/dl Creatinine 1,72 mg/dl Random blood glucose 237 mg/dl mg

Working Diagnosis

AKI Et Causa Gastroenteritis Akut DM type 2

Differential diagnosis

AKI Et Causa gastroenteritis Virus AKI Et causa Gastroenteritis bactery AKI et Causa Gastroenteritis amoeba CKD Lactose Intolerance

TREATMENT

NaCl 0,9 % 20 dpm Lasix 2x1 KSR 1X1 Ceftriaxone 2x1 Metformin 500mg 3x1 Renxamin 1 imm

Suggested examination

Electrolyte Stool examination Lipid Profile BGA

PROGNOSIS

AD VITAM : AD BONAM AD SANATIONAM : AD BONAM AD FUGSIONAM : AD BONAM

THANK YOU