BASED

DISCUSSI
ON
dr. Wignyo Santosa, Sp.An-KIC, FIPM

Kelompok :
 Maritasari
 Mayday Finisha P.
 Muhammad Rizal Nur F.
 Nadira Rizqi M.
 Naufal Aria P.
 Patient’s Identity

• Name : Mrs. NH
• Age : 61 y.o
• Gender : Female
• Religion : Moslem
• Job :-
• Address : Rejosari IV Genuk Sari RT 06 RW 04
• MR number : 01317428
• Room : Baitul Izzah 1 – J4
• Entry Date : February 19th 2020
HISTORY TAKING

Chief Complains : loss of

consciousness
History of present illness
2 weeks before came to Sultan
Agung hospital patient was diagnosed
with stroke. Since that day she can’t
speak fluently. One day before came
to Sultan Agung hospital patient loss
of consciousness
 HISTORY OF ILLNESS

HISTORY OF PREVIOUS FAMILY’S HISTORY OF SOCIO-ECONOMIC

ILLNESS HistoryDISEASE
of same illness HISTORY
(-)
History of same illness Hypertension history
(-) (-) Routine consume
Hypertension history DM history (+) water. Hospital cost
(+) Cardiac disease history certified by BPJS
DM history (+) (-)
Cardiac disease history Kidney disease history
(-) (-)
Kidney disease history
(-)
 GENERAL STATUS

BODY MASS INDEX

▪ Weight : 54 Kg ▪ Awareness : E2 M2 V1 (5)
▪ High : 160 cm ▪ Blood pressure : 170/100
mmHg
▪ BMI : 21.09 ▪ Heart rate : 84 x/minute
kg/m2 ▪ Breath frequency: 18 x/minute
▪ Temperature : 36.6 ºC

Intepretation :
Intepretation : Intepretation
Loss of :
Intepretation
Normoweight: Loss of
consciousness
Normoweight consciousness
Hypertension Grade
HypertensionII Grade
II
 PHYSICAL EXAMINATION
EYES
Conjungtiva
injection (-), sclera
icteric (-), pupil
reflect (+) THROAT
MOUTH
Pain swallow (-),
Cyanosis (-), thrush hoarseness (-),
(-) odinifagia (-)

SKIN
MUSCULOSKEL
Itching (-), Jaundice ETAL
(-), pale (-) Weak (+), rigid (-)

EXTREMITY
Oedem on lower Intepretation : oedem on
extremity (+) Intepretation : oedem
lower extremity, on
weakness
lower extremity, weakness
on musculoskeletal (dextra)
on musculoskeletal (dextra)
LUNG EXAMINATION

INSPEKSI ANTERIOR POSTERIOR

Static RR : 18x/min, Hyper pigment (-), spider nevi RR : 18x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, (-),spider nevi (-), Hemithoraks 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 (-), muscle
retraction of breathing (-), retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

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

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Ronchi (-)
Intepretation : normal
Intepretation : normal
CARDIAC
EXAMINATION

Inspection : Ictus cordis isnt seen.

Inspection : Ictus cordis isnt seen.
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-), sternal lift (-).
Percussion  : dull sound
Percussion  : dull sound
 Upper borderline of heart : ICS II left sternal line
 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parasternal line
 Waist of heart : ICS III left parasternal line
 Lower right borderline of heart : ICS V right sternal 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
 Lower left borderline of heart : ICS V, 2 cm lateral from left mid clavicle line
Auscultation
Auscultation
 Aortal valve: S1 & S2 standard, additional sound (-)
 Aortal valve: S1 & S2 standard, additional sound (-)
 Pulmonary valve: S1 & S2 standard, additional sound (-)
 Pulmonary valve: S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, additional sound (-)
 Tricuspid valve : S1 & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 standard, additional sound (-)
 Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : normal
Intepretation : normal
ABDOMEN
EXAMINATION

Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),

Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
caputmedusa (-).
Auscultation: peristaltic (+), 8x/minute
Auscultation: peristaltic (+), 8x/minute
Palpation :
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Superfisial : tight (-), mass (-), epigastrial pain (-)
• Deep : abdominal pain (+), liver, kidney, and spleen weren’t palpable,
• Deep : abdominal pain (+), liver, kidney, and spleen weren’t palpable,
Murphy’s sign (-)
Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
• Liver : deaf(+), right liver span 11 cm, left liver span 6 cm
• Spleen : Throbe space percussion (+)  tympani
• Spleen : Throbe space percussion (+)  tympani

Intepretation :
Intepretation :
Abdominal pain
EXTREMITY
EXAMINATION

Ekstremitas Superior Inferior

Ekstremitas Superior Inferior
• Oedema -/- +/+
• Oedema -/- +/+
• Cold -/- -/-
• Cold -/- -/-
• Jaundice -/- -/-
• Jaundice -/- -/-

Intepretation : Oedem
Intepretation : Oedem
lower extremity
Examination
Ureum
Value
170 mg/dL (H)
Normal values
10-50 mg/dL
LABORATORY
Blood Creatinin 12.35 mg/dL (H) 0.6-1.1 mg/dL
EXAMINATION
Haemoglobin 10 g/dL (L) 11,7-15.5 g/dL
Hematocrit 29.3 % (L) 33-45 %
Leukosit 11 ribu/dL 3.8-11.1 ribu/dL
Trombosit 235 ribu/dL 150-440 ribu/dL
Natrium 140 mmol/L 135-147 mmol/L
Kalium 6.18 mmol/L (H) 3.5-5 mmol/L
Chloride 104.6 mmol/L 95-105mmol/L
SGOT 20 U/I 0-35 UI
SGPT 21 U/l 0-35 UI

Intepretation : azotemia,
Intepretation : azotemia,
anemia, hyperkalemia,
anemia, hyperkalemia,
HEAD CT SCAN
NON CONTRAST
• Sulci, fussura and cysterna wider
• Hypodens lesion in parietal lobe and
semiovale centrum
• Calcification in ganglia basale right and
left
• Narrow ventrikel
• Deviation midline

Intepretation : infarct in
Intepretation
left parietal :lobe
infarct
andinleft
left parietal lobecentrum
semiovale and left
semiovale centrum
ECG
Rhytm : Sinus
Regularity: Regular
Frequency : 100 x/minute
Axis : lead 1 = +; AvF = +  NAD
Transition zone : -
P wave : 0,08 s (normal)
PR Interval : 0,20 s (normal)
QRS Interval : 0,06 s (normal)
Pathologic Q wave : -
ST Segment : elevated ST (-), depressed ST (-)
T wave : T flat (-), T tall (-), T inverted (-)

Intepretation :
Intepretation :
Normosinusrythm
Normosinusrythm
 AaBNORMALITIES DATA

PHYSICAL EXAMINATION
3. Loss of consciousness
4. Hypertension grade II
5. Oedem lower extremity
6. Weakness musculoskeletal
dextra
7. Abdominal pain

SUPPORTING EXAMINATION
8. Ureum increased
ANAMNESIS
9. Creatinin increased
1. Loss of consciousness
10. Hemaglobin decreased
2. Can’t speak fluently
11. Hematocrite decreased
12. Potassium increased
13. Infarct left parietal lobe
and left semioval centrum
CHRONIC KIDNEY DISEASE
5,7,8,9 01
HYPERTENSION GRADE II
4 02
ANEMIA
10,11 03
HYPERKALEMIA
12 04
STROKE NON HEMORARGIC
1,2,3,6,13 05
 CHRONIC KIDNEY DISEASE
assessment
Emergency condition 
to prevent metabolic
acidosis, over hidration
IP Dx
BGA, Chest xray
IP Tx
• Non pharmacologic
dialysis
• Pharmacologic IP Ex
keto acid and
essential amino acid • Explain about the
3x1 disease
• Explain about the
dyalisis
• Low intake of protein
IP Mx (0.6 – 0.8/ kgBB/day)
Vital Sign, GFR, general
• Calorie intake 30-35
state, awareness, fluid kkal/kgBB/day
balance (input : Infus.
Output : urine output, IWL)
positive effect : edema
pulmo, negative effect :
kidney disorder (increased
of ureum and creatinine)
 HYPERTENSION GRADE II

IP Tx
assessment • Captopril 2x12.5 mg
• Bisoprolol 1x1.25 mg
Benigna or maligna
IP Ex
• Low intake of salt
• Regular physical
activity
• lifestyle changes
IP Mx
Vital Sign
IP Dx
Funduscopy  grade of
retinopathy
 ANEMIA

IP Tx
assessment
• Sulfas ferrous
Anemia normositic
normochromic, anemia 1x200mg IP Ex
• Preparat EPO
hypochromic micrositic • Explain about
anemia
• High intake of iron
such as spinach,
liver chicken
IP Mx
Vital sign, HB, HT
IP Dx
MCV, MCH, MCHC,
complete blood count
 HYPERKALEMIA

IP Tx
Reduce cardiac cell membrane
excitability
assessment Calcium Gluconate 10% 10 mL IV
Arrhytmia, metabolic over 5 mins
acidosis Shift potassium from extracellular to IP Ex
intracellular space
INSULIN ACTRAPID® 10 units in • Explain about the
50 mL of Glucose 50% IV over 30 disease
minutes via volumetric pump

IP Mx
IP Dx General state,
BGA Awareness, ECG,
Vital Sign, kalium
status
 STROKE NON HEMORARGIC

IP Tx
assessment • Refer patient to
- neurologist
IP Ex
• Explain that the
patient will refer to
neurologist to get
medication for
stroke
IP Mx
Awareness, vital sign
IP Dx
-
  Laju Filtrasi Glomerulus (LFG) :

=
 
=
 
= = 5.64 Chronic Kidney
Disease Grade V
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 atau - Albuminuria (AER ≥ 30mg/24
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 glomerulus GFR < 60 ml/menit/1,73 m2

(GFR)
 Old Classification of CKD as Defined by Kidney Disease
Outcomes Quality Initiative (KDOQI) Modified and Endorsed by
23 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
27

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
 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.
 Algoritma Anemia Normokrom
Normositer
MCV/MCH
Normal

Darah Perifer

Jumlah Retikulosit
Normal/rendah Tinggi

Morfologi SS Tlg Hemolitik Perdaraha

n Akut
Norma Abnormal
l
Anemia Sekunder
Peny Ginjal, Hipoplastik Infiltrasi
Diserytropoisi
Fibrosis
Peny Hati s
Endokrin, Defisiensi Anemia Leukemia Myelodisplasi
Aplastik a
Algoritme anemia Hipokrom Mikrositer

Anemia Hipokrom Mikrositer

Serum Fe/TIBC

FE / TIBC A Def Besi

HbA1, HBF  Talasemia

FE  /
TIBC N
HbA1, HBH  Talasemia

FE  / A Sideroblastik
TIBC N

Ureum/Bu A Peny Kronis

FE / TIBC nN
 Ureum/Bun
A Peny Ginjal
Abn
 Algoritma Anemia Makrositer
Anemia Makrositer

ABN
LFT Peny Hati
Kronis
Folat 
As Folat/ Vit B12 A Def Folat

Vit B12
A Def B12

Vit B12/Folat N A Megaloblastik

Rwyt Tx Anti Metabolit Krn obat

BMB/BMP Sindroma
Myelodisplastik