CASE PRESENTATION

AND DISCUSSION
ON
CHRONIC KIDNEY
DISEASE

JEHANNA MAR E. ABDURAHMAN

LEVEL III ADZU SOM
GENERAL DATA:

This is a case of A.G., a 52 years old single female from Mercedes. She is a highschool

graduate and a Roman Catholic

CHIEF COMPLAINT:

Difficulty of Breathing

HISTORY OF PRESENT ILLNESS:

One month prior to admission (PTA), patient had sudden onset of difficulty of

breathing. Patient also observed exertional dyspnea, 3 pillow orthopnea, edema and oliguria.

No medications were taken and no consult was done.

One day prior to admission, due to persistence of symptoms patient sought consult at

Mindanao Central Sanitarium. Laboratory work ups were done where it was found out that

patient had increased BUN and Creatinine. Patient was then referred to ZCMC for

hemodialysis

PAST MEDICAL HISTORY:

Patient is a known hypertensive for five years now with maintenance medication of

Amlodipine and Losartan-allegedly compliant. No other co morbidities noted. No history of past

surgeries. No allergies noted

FAMILY MEDICAL HISTORY:

Patient has family history of hypertension and diabetes. No other heredofamilial diseases.

PERSONAL AND SOCIAL HISTORY

 Patient lives with her nuclear family. Patient is a known smoker with 40 pack years. She

is an occasional alcoholic drinker but denies illicit drug use. Patient’s usual diet consist of fish

and vegetables.

REVIEW OF SYSTEMS

General Survey Changes in weight seen. (+) fatigue (-)fever.

Skin No itching felt.

Head Head: With lightheadedness. No headache.

Eyes Eyes: No blurring of vision, ocular pain and excessive lacrimation. 

Ears Ears: No hearing changes, earaches or tinnitus.

Nose Nose and sinuses: No nasal stuffiness or nasal trouble.

Throat Throat (or mouth and pharynx): No frequent sore throat or gum bleeding.

Neck No neck pain and stiffness.

Cardiovascular No chest pain or discomfort, palpitations. 

Gastrointestinal No changes in bowel movement. No hematemesis, hematochezia.     

Urinary No dysuria or changes in urine color. (+) oliguria

Musculoskeletal No muscular, bone or joint pain.        

Endocrine No heat or cold intolerance, excessive hunger, excessive sweating and

excessive thirst.
PHYSICAL EXAMINATION

General Patient is awake, alert, conscious and oriented to 3 spheres. Patient is not in

respiratory distress. 

Vital Signs Temperature:  36.8 °C

Pulse Rate: 91  bpm

Respiration: 24  cpm

Blood Pressure: 160/100 mmHg

Oxygen Saturation: 99% at room air.

Skin Warm to touch with dry skin. No clubbing and smooth nails.

Head Equal hair distribution. No lumps or masses.

Eyes  Anicteric Sclerae, pink palpebral conjuctivae. Pupils 3mm, round and

equally reactive to light. Extraocular movements intact.

Ears Good hearing acuity, ears without discharge and deformities. No

Nose  tenderness.

Pink nasal mucosa, clear nasal cavity. Slightly flat nose. Septum at midline.

Throat No sinus tenderness.

Oral mucosa pink and moist. Tongue at midline.

Neck Neck supple. No masses. Nontender/nonenlarged cervical and

supraclavicular lymph nodes.

Thorax and With symmetrical chest excursion. No scars, lumps and tenderness. Lungs

Lungs resonant on percussion. (+) fine crackles on lower lung fields.

Cardiovascular Adynamic precordium. PMI at 5th ICS midclavicular line. Normal rate and

regular rhythm. No murmurs. No heaves or thrills.

Abdomen No scars. Normoactive bowel sounds. Nontender. No organomegaly noted.

Peripheral Capillary refill time < 2 secs. Good pulses. 

vascular

Extremities (+) edema on all limbs grade 2. Warm to touch.

Genitalia Not assessed.

I. CLINICAL DIAGNOSIS

Chronic Kidney Disease

Demographics History Physical Examination

 52 years old  Known hypertensive  BP: 160/100 mmHg

 Female for 5 years now  Fine crackles on lower

 Sudden onset of lung fields

difficulty of breathing  (+) Edema on all limbs

 Exertional dyspnea, 3 grade 2

pillow orthopnea and

edema.

 Oliguria

PRIMARY CLINICAL DIAGNOSIS: CHRONIC KIDNEY DISEASE

SECONDARY CLINICAL DIAGNOSIS: CONGESTIVE HEART FAILURE

 Chronic kidney disease over heart failure should clearly be considered as a clinical

impression in this case. First, the patient is 52 years old female with known hypertension for five

years. In this presentation alone, given that the age of the patient and his comorbid strongly

predisposes him to a cardiac or a renal condition given that these two has a direct relationship

together. Heart failure must also be considered because as stated in the history of present illness,

patient had sudden onset of difficulty of breathing, exertional dyspnea, 3 pillow orthopnea,

edema and oliguria which could be a manifestation of heart failure. Although the physical

examination findings showed elevated blood pressure and respiratory finding of fine crackles on

both lung fields, no significant cardiac findings such as elevated JVP and displaced PMI were

seen which strongly suggest that the manifestations were caused by a renal problem. Altogether,

these signs and symptoms may be due to damage to the kidneys caused by hypertension which

resulted in congestion due to inability to excrete waste from the body thus the secondary clinical

diagnosis of chronic kidney disease- chronic due to its time frame.

II. PARACLINICAL DIAGNOSTIC PROCEDURES

CLINICAL DIAGNOSIS CERTAINTY TREATMENT MODALITY

 CHRONIC KIDNEY 90% Dialysis and medical

DISEASE management would Be done

to remove excess waste

products thus decongesting

the patient

CONGESTIVE HEART 50% Medical management would

FAILURE be undertaken to decongest

the patient

PARACLINICAL BENEFIT RISK COST AVAILABILITY

BUN and Glomerular None Relatively low Readily available

Filtration Rate and cost
Creatinine BUN Crea ratio can
be measured thus
determining CKD.
Increased crea
indicates a damage
to kidneys

Renal Ultrasound It is useful to screen None 500-1000 Readily available

for small, echogenic
kidneys which could
be observed in
advanced renal
failure. Other
structural
abnormalities may
also be seen.

In this patient, BUN and Crea must be assessed initially to determine Elevated creatinine

level signifies impaired kidney function or kidney disease. A more precise measure of the kidney
function can be estimated by calculating how much creatinine is cleared from the body by the

kidneys. This is referred to as creatinine clearance and it estimates the rate of filtration by

kidneys (glomerular filtration rate, or GFR). The creatinine clearance can be measured in two

ways. It can be calculated (estimated) by a formula using serum (blood) creatinine level, patient's

weight, and age. The formula is 140 minus the patient's age in years times their weight in

kilograms (times 0.85 for women), divided by 72 times the serum creatinine level in mg/dL.

Creatinine clearance can also be more directly measured by collecting a 24-hour urine sample

and then drawing a blood sample. The creatinine levels in both urine and blood are determined

and compared. Normal creatinine clearance for healthy women is 88-128 mL/min. and 97 to 137

mL/min. in males (normal levels may vary slightly between labs). Blood urea nitrogen (BUN)

level is another indicator of kidney function. Urea is also a metabolic byproduct which can build

up if kidney function is impaired. The BUN-to-creatinine ratio generally provides more precise

information about kidney function and its possible underlying cause compared with creatinine

level alone.

PARACLINICALS

1.  CBC – decreased hemoglobin

2.  ECG- to determine the cardiovascular status and assess hypertrophied heart chambers. Left

ventricular hypertrophy

3.  Creatinine- elevated

Aside from the abovementioned paraclinicals, I highly suggest to assess electrolytes also.

III. TREATMENT

PRIMARY CLINICAL DIAGNOSIS: CHRONIC KIDNEY DISEASE

SECONDARY CLINICAL DIAGNOSIS: CONGESTIVE HEART FAILURE

GOALS

1. To decrease the likelihood of CKD progression

2. To alleviate signs and symptoms

3. To improve quality of life

MANAGEMENT BENEFIT RISK COST AVAILABILITY

NONOPERATIV Noninvasive Potential side Slightly Readily available

E effects of expensive due
Highly medications to multiple
beneficial if medications
patient is
compliant

OPERATIVE Indicated for IJ Invasive Highly Readily available

catheter Complications expensive
insertion for intra op and
emergency post op may
dialysis arise

The data on how the patient was treated is not available. However, in patients with CKD,

control of blood pressure is vital therefore ACE inhibitors or ARBS should be given together

with diuretics to help optimize hypertension control and to attenuate disease progression.

Diuretics may also help control serum potassium. Hemodialysis may also be indicated especially

for patients with severe volume overload refractory to diuretic agents, severe hyperkalemia

and/or acidosis, severe encephalopathy not otherwise explained, and pericarditis or other

serositis. Additional indications include symptomatic uremia and protein energy

malnutrition/failure to thrive without other overt cause.

EVALUATION

Management of the patient should be evaluated by re assessing the goals of the treatment

1. To decrease the likelihood of disease progression

2. To alleviate signs and symptoms

3. To improve quality of life

IV. PREVENTION AND HEALTH PROMOTION

 Dietary

1. Weight loss

2. Sodium restriction

3. Protein restriction

4. Smoking cessation

5. Fluid restriction

6. Ensure compliance to medications

Since hypertension can cause a lot of diseases in the long run, we must advise

hypertensive patients to seek consult of a physician for follow up annually. Diet modification

should be also observed and emphasized. Maintenance medications must be taken

religiously. Moreover patients with strong family history of renal diseases must be advised to

seek consult for early screening and detection.

V. REFERENCES
Jameson, Larry, et. al. 2018 Harrison’s Principles of Internal Medicine, Chronic Kidney
Disease p. 2111
medicinenet.com/creatinine_blood_test/article.htm retrieved last 03/19/2020