Case Report

CASE REPORTA 58 YEARS OLD MAN WITH STAGE V CHRONIC KIDNEY DISEASE, STAGE II

HYPERTENSION, AND NORMOCHROMIC NORMOCYTIC ANEMIA

GESTANA ANDRU

G6A 009 077

Dr. DWI LESTARI Sp.PD KGH

IDENTITY

• Name : Mr. M• Age : 58 yo• Sex : Male• Education : Elementary graduated• Occipetion : Unemployment• Address : Menganti, Jepara• Admission Date : March 24 2011• Reg No : 6575182

DAFTAR MASALAH

NO ACTIVE PROBLEMS DATE NO PASSIVE PROBLEM

DATE

1

2

3

Stage V Chronic kidney Disease with Hyperkalemia

Stage II Hypertension with LVH

Normochromic Normocytic Anemia

25/03/2011

25/03/2011

25/03/2011

ANAMNESIS March 25 2011 at C3C ward

• Chief Complaint: Weakness

12 days agoWeakness (+), gradually, all day long, daily activity

disabled

OTHER SYMPTOMS

Positives Negatives

1. Dizziness2. Tiredness3. Loss of appetites4. Palpitation5. Swollen leg6. Less micturition (1,5

glass/day)

1. Fever2. Blurred vision3. Cough and influenza4. Epistaxis5. Vomiting6. Gastric pain7. Cachexia8. Low back pain9. Painful micturition

ANAMNESIS March 25 2011 at C3C ward

• Chief Complaint: Weakness

RSDK

12 days agoWeakness (+), gradually, all day long, daily activity

disabled

10 days at RS KartiniBlood lab, Chest X-ray

Ultrasound

2 days agoHD neededPatient was

reffered

MEDICAL HISTORY

• History of hypertension for 18 years, uncontrolled, medication taken but the patients couldn’t recall it

• History of diabetes, asthma, heart disease, lung disease was denied

• History of black “tarry” feces about a month ago• History of fever and accompanied by painful and

frequent urinating was denied

Family History• History of similar symptoms and signs was denied• History of diabetes, hypertension, heart disease was

denied

Socioeconomic Profile• Low economic state

PHYSICAL EXAMINATION (MARCH 25 2011)

• General condition: severely ill• GCS : E4M6V5 : 15

VS:

BP: 160/100 mmHgPulse: 82 x/minRR: 20 x/minTemp: 37oC

Anthropometry assessmentBW: 55 kgs Height: 1.60 m

BMI: 21.48 (normoweight)

Paleness of conjunctival

palpebra (+/+), oedema (-/-)

ENT: discharge (-)

JVP N, nodes enlargement (-),

deviation of trachea (-)

COR:I: ictus cordis not visible

Pal: IC was palpated on the VIth ICS, 2cm lateral from left midclav line, widened beat (-), finger lifting(+), thrill (-), sternal lift (-), left parasternal pulsation (-), epigastrial pulsation (-)

Per:heart configuration•Upper: 2nd ICS left parasternal line•Right: 2nd ICS right parasternal line•Left: Vith ICS 2cm lateral to left midclav line•Base of the heart flattened

•Aus: HR: 60 beats/min, holosystolic murmur (+) grade 2/6 on apex cordis to the axilla

LUNGS EXAM, Anterior and Posterior Aspects

•Ins: lungs expansion was symetricRate and pattern was normal

•Pal: lungs expansion was symetric, tactile fremitus was symetric

•Per: Resonant in all area of the lungs

•Aus: Breath sounds :vesicular on the both sides of lungs, no ronchi, wheezes, or rales were found

Abdomen

• Ins: the abdomen was distended

•Aus: bruits (-), loss of bowel sounds (-), hyperactive sounds (-)

•Per: liver size normal, shifting dullness (-)

•Pal: hepatosplenomegaly was not found, tenderness (-)

Extremity:

Cyanosis (-)

Oedema (-)

Capp Refill <2’’

LABORATORY FINDINGSHaematology Normal

Range23/03/11

RS KartiniNormal Range

24/03/11RSDK

25/03/11RSDK

Hb (g%)Ht (%)RBC(10 6 /mm3)MCV (fl)MCH (pg)MCHC (g/dl)WBC(10 3 /mm3)Platelets(10 3 /mm3)

14 – 1840 - 48

(-)

(-)(-)(-)

5 – 10

150 – 400

7.120.4(-)

(-)(-)(-)8.7

270

13 – 1640 – 54

4.5 – 6.5

76 – 9626 – 3229 – 364 – 11

150 – 400

8.3024.52.90

84.4028.5033.807.20

224.0

9.0026.63.16

84.2028.4033.706.80

222.0

Findings: Anemia Normocythic Normochromic Anemia

Normocythic Normochromic Anemia

NormalRange

22/03/2011RS Kartini

NormalRange

23/3/2011RS Kartini

BGL (mg/dl)Ureum (mg/dl)Creatinin (mg/dl)AlbuminNa+ (mmol/l)K+ (mmol/l)Cl- (mmol/l)Ca (mmol/l)

80 - 15010 - 50

0.8 – 1.2 

136 - 1464.4 – 4.8

 8.1 – 10.4

136297.2

10.2-

1367.1-

9.6

Bilirubin totBilirubin dirSGOTSGPTGamma GTALPBlood type

0 - 10 – 0.2515 -389 – 4211 – 61

64 – 644

0.590.15343628

191B Rh (+)

Findings AzotemiaHyperkalemia

CREATININ CLEARANCE TIMECockcroft-Gault Formula

• CCT : (140-age) x Body weight

72 x Creatinine• (140 – 58) x 55 = 6.14 ml/minutes/1,73m2

72 x 10.2

• Imunology (March 23 2011)• HbsAg (-)

ABDOMINAL ULTRASOUND (03/21/2011)Findings : Chronic process on both kidney with

contracted kidney

ECG Dat Emergency Ward(24/03/2011)

Rythm : sinus, HR : 51 x/minute, Axis: normoaxis Trantition zone: at lead V3, V4

P wave : 0,08 s, Pulmonal P wave (-), Mitral P wave (-), PR Interval:0,18s QRS wave : 0,12 s, Q Patologic wave (-), T wave: tall T wave (-), inverted T wave (-)Segment ST: isoelektric, SV1 + RV5/V6 >35, R/S <1,

Findings: Sinus Bradychardia with LVH

RESUME• A 58 yo male patient came to the emergency ward of RSDK with chief

complaint: weakness, patient needed help to conduct daily activities. Patient was reffered from RS Kartini, and had been treated for 10 days,

blood lab, ultrasound, and chest X ray was conducted and the results showed chronic kidney disease and hemodialysis was needed, and the

patient was reffered to RSDK.

• Dizziness (+), fatigue (+), nausea (+), palpitation (+), loss of appetite (+), dyspneu (+), swollen legs (+), lessening micturition (+)

• On physical examination, the patient was severely ill, vital signs : BP: 160/100 mmHg, RR 20 x/min, pulse 82 x/min, BMI was normoweight

• Further exam showed the left ventricle hypertrophy with sholoystolic murmur grade 2/6 on the apex to axilla, no anomalies in the lungs, abdominal exam showed no abnormalities, kidney ballotement (-),

edema was found in the inferior extremities.

• Laboratory findings showed normochytic normochromic anemia, azotemia, and hyperkalemia

• Ultrasound showed chronic process on both kidney with contracted kidney

• Electrocardiography showed sinus bradychardia, left ventricle hypertrophy

LIST OF ABNORMALITIES• Weakness -Dizziness• Fatigue -Nausea

Palpitation -Dyspneu• Loss of appetite -Lessened micturition• History of melena -Hitory of 18 years with hypertension• BP160/100 mmHg -Paleness of conjungtival palpebrae• Dryness, Paleness of buccal mucosa• Ictus cordis was palpated on Vith ICS 2 cm lateral from ileft midclav line• Systolic murmur grade 2/6 on apex to axilla• Oedema on inferior extremity -Hb: 9.00 gr%• Erithrocyte: 3.16 jt/mm3 -Ureum: 297.2 mg/dl• Creatinine: 10.2 mg/dl -Hyperkalemia• CCT 6.14 ml/menit/1.73 m2

• Ultfrasound: Chronic process on both kidney with contracted kidney• ECG: Left ventricle hypertrophy

PROBLEMS

1. Stage V CKD with hyperkalemia

2. Stage II Hypertension with LVH

3. Normochromic Normocytic Anemia

INITIAL PLAN• Problem 1. CKD Stage V with Hyperkalemia• Ass : - Determining etiology:- Nefropatic Hypertension • - Primary Glomerulonephrytis• - Detremining bleeding complication• IP • Dx : Urinalysis, uric acid, PPT/PTTK, feces analysis, kidney biopsy• Rx : - RL infusion drip 12 dpm

• Ca Gluconas Inj 1 vial• - Kalitake tablet 3x1

• - Kidney replacement therapy with hemodialysis• - uremic soft food diet 30 g of proteins, low salt 1900 cal

• Mx : ureum serum,creatinine serum, , electrolyte, fluid balance

• Motivate to patient to measure urinary output and maintain the fluid taken according to the urine

• Motivate the patient and family not to take any other food beside what the hospital gave him

• Motivate the patient and family to follow the schedule of hemodialysis

Problem 2. Hypertension Stage II with LVH

Ass : Determining risk factor and target organ complication (hypertensive retinopathy, hypertensive neuropathy, hypertensive nephropathy, Ischaemic Heart Disease)

IP Dx : Blood Glucose, Lipid Profile, Funduscophy, EMG, ECGRx : - Valsartan 1 x 80 mg

- Diltiazem 3x60 mg

- Low Salt dietMx : KU,TVEx : -Motivate the patient to maintain the medication taken and low salt diet,

avoid stress, and regular check up for the target organ impairment

• Problem 3 : Normochromic Normocytic Anemia• Ass : - chronic disease• - bleeding• - iron deficiency• IP• Dx : Blood cell morphology, reticulocythe, TIBC, ferritin

serum, transferrin serum• Rx : PRC transfusion 1 pack with 1 vial lasix injection• Mx : Vital signs, Hb serials• Ex : -

THANK YOU