Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2017

Case Based Discusion

Arif Wicaksana
30101206755
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient Identity

Name : Mr. A
Age : 36 y.o.
Gender : Male
Religion : Moslem
Job : Online Seller
Address : Perum Mutiara hati Blok-D No.8 Karangroto Genuk
MR number : 01076995
Room : Baitul Izzah 1 – 402.2
Entry date : March 3rd, 2017
Date out : March &th, 2017
History taking

Main Problem
• Nausea

History of present illness

• Patient come as outpatient to the clinic on Sultan Agung Islamic hospital
with nausea that does not heal after several week. His nausea does not
heal after he takes some medication that he usually took. Patient also
came with headache. After a week of medication the headache and
nausea is still remain as the problem of patient, than the doctor was giving
advice to have an USG. A week after USG patient came with worse
condition beside headache and nausea, he also complain about limp,
and decreased body weight.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
Hypertension history (+)
Hospital cost certified by
DM history (-)
“BPJS-PBI”
Asthma history (-)
Alergy history (-)
SMOKING (-)
Uric Acid (+)
FAMILY’S HISTORY OF DISEASE

Hypertension history (+)

DM history (+)

Asthma history (-)

SISTEMIC ANAMNESIS
Chief Complains : Nausea

Onset : 3 weeks ago

Location : Abdomen

Chronology : Patient was having nausea on several weeks hat does

not heal after 3 times medication on RSISA,

Quality and Quantity : His nausea was coming everyday and everytime
without spesific condition

Modification factor : Better when she took a rest

Comorbid complains : Geadache, Weight loss, limp

 PHYSICAL EXAMINATION
General : composmentis Throat : pain swallow(-), hoarseness (-),
Skin : itching (-), jaundice (-), pale (-) odinifagia (-)
Neck : enlargement of the gland (-)
Head : headache (+)
Chest : cough (-), sputum (-), blood (-)
Eyes : blurred vision (-), red eyes (-),
Cardiac : chest pain (-), palpitations (-)
icteric sclera (-/-)
Digestive : abdominal pain (-), nausea (+),
Ears : hearing loss (-), ring (-), vomiting (-)
discharge (-) Musculoskeletal : weak (-), rigid (-), back pain (-)

Nose : nosebleed (-), discharge (-) Extremity : oedem extremity (-)

Mouth : cyanosis (-), thrush (-),

bleeding gums (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 60 BMI= 60/(1.6 x1.6) = 23,4
High : 160
Intepretation :
Normoweight

General : Nausea
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
• Blood Pressure : 150/90 mmHg
• Heart rate : 80 x/minute
• Breath Frequency : 24 x/minute
• Temp : 36,0oC
Intepretation :
Hypertension grade 1
GENERAL STATUS
Head : Mesocephal, alopesia (-)

 Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)

 Nose : symmetric, secret (-), Nostril Breath (-)

 Ears : Normal Shape, discharge (-/-)

 Esophagus : Hyperemic (-), pain devour (-)

 Mouth : Cyanosis (-), dry lips (-),

 Neck : Trakhea deviation (-), Lymph Hypertropy (-)

 Extremity : Oedem of lower extremity / upper extremity (-) / (-)

Intepretation : Normal
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle abdominothorakal breathing (-),
retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus
angle < 900, enlargement of ICS (-), Stem costae angle < 900, enlargement of
fremitus D=S ICS (-), Stem fremitus D=S

Percution Sonor Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Intepretation :
Ronchi (-) NORMAL
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion : dull sound

 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS V, 2 cm lateral from left
mid clavicle line
 ...CONT

Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)

 Pulmonary valve: S1 & S2 standard, additional sound (-)

 Tricuspid valve : S1 & S2 standard, additional sound (-)

 Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : NORMAL
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (-), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
• Spleen : Throbe space percussion (+)  tympani

Intepretation : Normal
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

• Oedema -/- -/-

• Cold -/- -/-

• Jaundice -/- -/-

Laboratorium Examination
 10/02/2017 03/03/2017 05/03/2017 05/03/2017 06/03/2017 Normal values
Uric Acid 9.7 mg/dL (H) - - - -
Ureum 238 mg/dL (H) 243 mg/dL(H) - - 99 mg/dL (H) 10-50 mg/dL
Blood Creatinin 14.80 mg/dL 21.06 mg/dL(H) - - 8.29 mg/dL (H) 0.6-1.1 mg/dL
(H)
Haemoglobin - 5.8 g/dL (L) 7.1 g/dL (L) - 10.1 mg/dL (L) 13.2-17.3 g/dL

Hematocrit - 18.2 % (L) 20.8% (L) - 28% (L) 33-45 %

Leukosit - 3.13 ribu/dL(L) 3.48 ribu/dL(L) - 4.30 ribu/dL 3.8-10.8 ribu/dL
Trombosit - 113 ribu/dL (L) 111 ribu/dL (L) - 116 ribu/dL (L) 150-440 ribu/dL
HbSAg - - - Negative -
Natrium - 137.8 mmol/L - - - 135-147 mmol/L
Kalium - 5.83 mmol/L - - - 3.5-5 mmol/L
(H)
Chloride - 107.7 mmol/L - - - 95-105mmol/L

Magnesium - 9.1 mmol/dL - - - 1.6-2.4 mmol/L

Calcium - 9.1 mg/dL - - - 8.8-10.8 mmol/L
Fe - 93 ug/L - - - 70-200 ug/L
TiBC - 165 ug/L (H) - - - 44.8-80.6 ug/L
Anorganic - 5.5 mg/dL - - - 2.5-5.0 ug/L
Phosphat
Interpretation

 ↑ Uric Acid (hiperuricemia)

 ↑ Ureum
 ↑ Creatinin
 ↓ Haemoglobin (Anemia)
 ↓ Hematocrytes
 Pansitopenia
 ↑ TiBC
 ↑ Kalium (hiperkalemia)
USG Examination
Left and right kidney size become
smaller with chronic kidney process
imaging (contracted kidney)
Chest X-Ray

Cor : tidak membesar

Pulmo : tak tampak kelainan
 Abnormal Data USG :
6. Contracted kidney

History Taking Physical Lab

7. ↑ Uric Acid (hiperuricemia)
1. Nausea, Examination
8. ↑ Ureum (Azotemia)
2.Headache. 3. Limp 5.High blood 9. ↑ Creatinin
10. ↓ Haemoglobin (Anemia)
4. Weight loss pressure : 150/90
11. ↓ Hematocrytes
12. Pansitopenia
13. ↑ TiBC
14. ↑ Kalium (hiperkalemia)
Problem List

1 CKD
3 Anemia 5
(1,2,3,4,6,8, Hiperkalemi
(10,11,12,1 (14)
9)
3)

2 Hypertension
4 Hiperuricemi
grade I (5) (7)
  Assassement : emergency condition  to prevent
CKD metabolic acidosis, seizure, hyperkalemia, bleeding,
crisis hypertention, over hidration, infection.
 IP Dx : BGA
 IP Tx :
 Non pharmacologic :
 Limitation of protein intake (0.6-0.8/kgBB/day),
 Calorie Intake 30-35 kkal/kgBB/day
 Dialysis
 Pharmacologic :
 CaCO3 3x1

 IP Mx
 Vital Sign, GFRLFG, uremic sign, general state, awareness,
fluid balance
 IP Ex
 Explain to the patient about the disease
 Explain about dialysis
 Take medicine regularly
 Explain side effect of medication
 Explain about proper daily intake, including type of diet and food
 Routine Control of Blood Pressure
Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿
140−36 𝑥60 (𝑘𝑔)
= 𝑚𝑔
72𝑥21.06( )
𝑑𝐿
6240 Chronic Kidney
= = 4,11
1516,32 Disease Grade V
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 - Albuminuria (AER ≥ 30mg/24
atau lebih) jam; ACR ≥ 30mg/g (≥3
mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau
lainnya yang berkaitan
dengan gangguan tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi GFR < 60 ml/menit/1,73 m2
glomerulus (GFR)
 Old Classification of CKD as Defined by Kidney Disease
25 Outcomes Quality Initiative (KDOQI) Modified and Endorsed
by KDIGO
Stage Description Classification Classification
by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
Rencana Tatalaksana Penyakit Ginjal Kronik sesuai
dengan derajatnya (Sudoyo, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 ≥ 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 Indikasi hemodialisa
Hemodialisis segera atau
emergency
• Uremia ( BUN >150mg/dL)
• Oliguria (urin < 200ml/12jam)
• Anuria (urin < 50ml/ 12jam)
• Asidosis berat (pH < 7.1)
• Hiperkalemia
• Ensefalopati uremikum
• Neuropati Uremikum
• Hipertermia
• Disnatremia (Natrium > 160
atau < 115 mmol/L)
Hemodialisis kronik, yaitu
hemodialisis yang dilakukan
seumur hidup
• Dimulai apabila dijumpai
salah satu gejala yaitu :
• a. LFG < 15ml/menit,
tergantung gejala klinis
penderita
• b. Malnutrisi atau hilangnya
massa otot
• c. Gejala uremia antara lain
anoreksia, mual muntah,
lethargy
• d. Hipertensi yang susah
dikontrol
• e. Kelebihan cairan
 KOMPLIKASI
31
32 NUTRISI PADA PASIEN CKD :
KOMPOSISI MAKRONUTRIEN DAN MINERAL

Adapted from DASH (dietary approaches to stop hypertension) diet.

*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.

*(CKD Stages 1-4)

NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-
S179.
Hypertension
Grade I  Assassement
 IP Dx : retinopati, LVH
 IP Tx : funduscopi, Chest X-Ray
 Non Pharmacologic
 Lowering salt intake on 5 g/day of NaCl

 Pharmacologic
 Irbesartan 300 mg 1x1

 IP Mx :
 Vital Sign(Blood Presure), General state, Awareness
 IP Ex
 Explain about Hipertension
 Motivating to change into better lifestyle (include more activity 3-4 days a week,
low sodium diet, and high fiber diet)
 Take medication regularly
Hiperurisemia
 Assassemen : nefrolitiasis, tofus
 IP Dx :
 IP Tx :
 Pharmacologic
 Allopurinol 100 mg 0-0-1
 IP Mx
 Uric Acid, Pain,
 IP Ex
 Avoid Organ meats high in purine contains ( liver, kidney,
seafood)
 Avoid sweetened soda beverage
 Do Excercise
 Stay well hydrated
a
Anemia  Assassemen : anemia mikrocytic hipochromic, anemia
normositic normochromic, anemia makrositic
 IP Dx : eritrocyte morphology examination (MCV, MCH,
MCHC), complete blood count
 IP Tx :
 Non pharmacological : PRC tranfsusion 2 colf
 Pharmacological : Folic Acid 1x1, EPO preparat
 IP MX
 General state, Awareness, Vital Sign, Routine blood (Hb, Ht)
 IP Ex
 Explain about Anemia
 Explain about treatment of anemia
 Explain about side effect of anemia’s treatment
Hiperkalemi
 Assassemen : Cardiotoxic, Metabolic acidosis
 IP Dx : ECG,BGA
 IP Tx : Hemodialysis, dietary restriction
 IP Mx
 General state, Awareness, ECG, Vital Sign, kalium status
 IP Ex
 Explain about disease
 Explain about treatment and side effect