Case Report

A 35 year old Man Came In

With Severe Shortness of
Breath Since 3 Days Before
Admission

By:
Jeshwinder Kaur J.S, S.Ked
Dodi Maulana, S.Ked

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI,
FINASIM

Introduction

CKD

KDOQI: kidney damage or a decreased glomerular

filtration rate (GFR) of less than 60 mL/min/1.73 m2 for 3 or
more months.
Various etiology:
Infection
Chronic hypertension
Autoimmun
Glomerulonephritis
Drugs
Obstructive uropathy
Incidence increase with
age, US: 4% at age 29-39
y; 47% at age >70 y
Pernefri 2004: 70.000
people suffer from CKD

Introduction cont...

metabolic
acidosis

hypertension

bone
disease

anemia of
chronic
disease

electolytes
imbalance

Case
Illustration

Identification
Name

: Mr. Riza Pahlevi

Age

: 35 years old

Sex

: male

Religion

: Islam

Status

: Married

Occupation : Farmer
Address

: Gelumbang village, Dusun III, No. 024, Muara Enim

Medical Record: 949980

Date of Admission: April 29th 2016 10:32 p.m

Anamnesis
CHIEF COMPLAINT
shortness of breath since 3 days before
admission

Anamnesis (History Of Illness)

07/05/16

3 months before admission, patient complained decreased urination per amount 4 glasses
day including bubbles in urin, urine sediment (-), red urine (-), cloudy urine (-), fever (-),
Cough (-), shortness of breath (-), he also complained that he didnt get sweat even after
hard work or even in hot weather
2 months before admission, patient complained about swelling over the whole body
occured in the morning after awakening, decreased in urination 1 glass per day
including bubbles in urine, mild shortness of breath while at rest. Patient went for
treatment at Prabumulih Hospital and was admitted for 3 days, no signs of recovery.
Patient was later transferred to Siti Khodijah Hospital and was informed that patient is
having Chronic Kidney Disease which needed haemodialysis. Patient had two sessions
of haemodialysis treatment. Swelling decreased and patient was discharged.
Then for 3 weeks patient didnt continue his medication and sought for traditional
medication and given some herbs to drink, but the complaint did not relieve.
3 days before admission patient complained of massive shortness of breath during
activity and also at rest, eyes and feet swelling was present. Urination decreased
massively to 1/2 glass per day with bubbles in it. Patient then came to Emergency
Department of Moh. Hoesin General Hospital and was hospitalized.

Anamnesis (History of past

illness)

History of uncontroled hypertension since 3 years ago

History of smoking since 16 years old 1 box/ day

History of typhoid fever 5 years ago

Anamnesis (History of familial

disease)

Family history was free from hypertension and diabetic

History of kidney disease and heart disease on the maternal side.

Physical Examination
07/05/16
GENERAL CONDITION

General appearance

: looked moderately sick

Conciousness

: compos mentis

Blood pressure

: 150/90 mmHg

Pulse rate

: 56x/minute, regular

Respiration rate

: 24x/minute, regular

Temperature

: 36,5 C

Body weight

: 52 kg

Body height

: 168 cm

Physical examination
(Specific condition) 07/05/16

Physical examination (Specific condition) cont...

Physical examination (Specific condition) cont...

Physical examination (Specific condition) cont...

No swelling

Additional examintion
No

Laboratory

Result

Result

29/04/ 2016

02/05/2016

6100Normal Value

Interpretation

Hemoglobine

6,4

7,9

13-17 g/dL

Anemia

Erythrocyte

2,20

2,79

4,00-5,70 103/mm3

Erythropenia

Hematocryte

18

22

35-45vol%

Low

Reticulocyte

0,5-1,5

High

Leukocyte

6000

8000

4700-11000/mm3

Platelet

172

195

189-436 103/L

Diff count
Basophil

0-1 %

Eosinophil

1-6 %

Segment

2-6 %

Band

40

61

50-70 %

Lymphocyte

46

33

25-40 %

Monocyte

2-8%

Trombocytopenia

Additional examintion cont...

No

Laboratory

Result

Result

Normal Value

Interpretation

29/04/2016
449

01/05/2016
331

16,6-48,5 mg/dl

Hyperuremia

31,52

21,35

0,5-0,90 mg/dl

High
Iron Defficiency

Ureum

10

Creatinine

11

Iron (Fe)

24

61-157 g/L

12

TIBC

112

112-346 g/dL

13

Ferritin

2210

13-400 ng/ml

High

14

Ca

8,8

9,1

8,8-10,2 mg/dl

Normal

15

Na

138

136

135-155 mg/dl

Normal

16

4,1

5,3

3,5-5,3

Normal

Urinalysis
17

Protein

++

18

Glucose

19

Blood

Additional examintion cont...

Thorax X-Ray
Cardiomegaly
Edema pulmonum

Additional examination
planning

HB After Transfussion

Echocardiography

ECG

DISCUSSION

DISCUSSION cont...
Degradation of kidney function: very low urine output and bubbles in
urine for 3 month, ECF overload (edema)
Patients GFR, estimated with cockcroft gault equation: GFR= [ (140Age) x bodyweight] / [72 x plasma creatinin] GFR= 2,4 mL/min/1,73 m 2
Urinalysis: mild proteinuria, hematuria,

Framingham criteria: Major: Increased JVP, edema pulmonum,

cardiomegaly Minor: Edema in lower extremities, Hepatomegaly,
dipsnea deffort
CHF: at least 1 major 2 minor

Working Diagnosis: CKD Stg 5 ec. glomerulonephritis + CHF +

Anemia Chronic disease

DISCUSSION cont...

Treatment:
Pharmakology
therapy for this patient include furosemid
2x20 mg IV, valsartan 1x80 mg tablet per
oral, ambroxol syrup 3x1 spoon per oral,
blood transfusion packed red cell 450cc,
folic acid 3x1 tab
Non Pharmacology
Bedrest
Diet : Protein (normal diet= 1-1,2 gr/KgBB)
and Water(urine output+IWL)

DISCUSSION cont...

CKD: degradation (GFR<

60 mL/min/1.73 m2 ) of
kidney function for 3
months or over
CKD can lead to the
development of CHF,
three major mechanisms
induced cardiomyopathy
and induce LV failure:
Pressure overload
Volume overload
CKD associated nonhemodynamic factors

DISCUSSION cont...

Congestive heart failure

the heart fails to pump blood in sufficient
numbers to meet the metabolic
requirements (unequal supply with demand),
or the heart to work properly only when the
filling pressure (ventricular filling) is
increased.
Heart failure is also a final state (end stage)
of any heart disease, including
atherosclerosis of the coronary arteries,
myocardial infarction, heart valve
abnormalities , and congenital

DISCUSSION cont...

Integrated Progress
Date

Time

Intergrated Progress Note

8/05/20
16

06.30

S : Shortness of breath getting better

O : General Condition
CM, light pain, BP : 150/90, HR : 102, RR: 26
Head: Pale conjunctiva (+), sclrea icterus (-)
Neck: JVP (5+2) cm H2O,
Thoracal
Cor: HR 102, Murmur (-) Gallop (-)
Pulmo: Vesicular (+) , Ronkhi (+), Wheezing (-)
Abdomen: convex, hepar is palpable 4 fingers bellow arcus costae,
Spleen is not palpable, shifting dullness (+)
Extrimity: edema pretibia (+/+)
A: mild Anemia e.c chronic disease /DD iron defficiency
CKD stg 5 ec. glomerulonephritis
CHF
HTN stg. I
P: Nonfarmacology :
Bedrest, O2 3 L, water restriction diet,normal protein diet,
education
Farmacology :
IVFD RL gtt x/m (mikro)
Inj. Furosemid 3x 20mg
Ambroxol syrup 3 x 1 C
pro HD
valsartan 1x 80mg PO
Folavit 3 x 1 tab

Integrated Progress

Integrated Progress
Date

Time

Intergrated Progress Note

8/05/20
16

06.30

S : Shortness of breath getting better

O : General Condition
CM, light pain, BP : 140/90, HR : 96, RR: 24
Head: Pale conjunctiva (+), sclrea icterus (-)
Neck: JVP (5+2) cm H2O,
Thoracal
Cor: HR 96, Murmur (-) Gallop (-)
Pulmo: Vesicular (+) , Ronkhi (+), Wheezing (-)
Abdomen: convex, hepar is palpable 4 fingers bellow arcus costae,
Spleen is not palpable, shifting dullness (+)
Extrimity: edema pretibia (+/+), showed improvement
A: mild Anemia e.c chronic disease /DD iron defficiency
CKD stg 5 ec. glomerulonephritis
CHF
HTN stg I
P: Nonfarmacology :
Bedrest, O2 3 L, water restriction diet,normal protein diet,
education
Farmacology :
IVFD RL gtt x/m (mikro)
Inj. Furosemid 3x 20mg
Ambroxol syrup 3 x 1 C
valsartan 1x 80mg PO
Folavit 3 x 1 tab

Integrated Progress

THANK

YOU