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1. What are the patient’s problems?
 Hypertension
 Diabetes
 Pruritis
 Lethargy
 Lower extremity edema
 Nausea
 Emesis
Physical Examination:
 Blood pressure : 180/110 mmHg ( N: 120/80 mmHg)
 Pulse : 80x (N: 60-100x/menit)
 RR : 24x (N: 12-20x/menit)
 Body weight : 76,5 kg
 Funduscopic : A-V nicking and copper wire
 Cardiac exam : Gallop rythm

2. "presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis." what does the
symptoms suggest to you?
Uremia: Symptoms of uremia are are non-specific. You have to keep this possibility in mind whenever there is consideration
for renal disease.
 Lethargy
 Nausea and vomiting
 Fatigue
 Lethargy
 Pruritus

3. What are the fundus changes in a hypertensive?

 AV nicking
 Hemorrhage
 Papilloedema

4. What are the fundus changes of a diabetic?

 Exudates
 Hemorrhage
 Neo-vascularization
 Aneurysms

5. What cardiac findings will you expect to find in a hypertensive?

Pressure work
 Apical impulse low and out
 Sustained apical impulse
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 Loud A2 component over aortic area

 S4
 Gallop

6. What are the possibilities for his lower extremity edema?

 Congestive heart failure
 Hypoalbuminemia
 Water retension from renal failure

7. Why was a renal ultrasound ordered? What information can you gather from renal ultrasound studies?
To determine kidney :
 Size
 Echogenicity
 Rule out obstruction

8. How does the results of the renal ultrasound influence your thinking on the diagnosis? What is the normal size of the
kidney? Is his kidney size normal? What does small or large kidney signify?
 Normal
 Large: Consider
 Small: Consider (mengecil karena fibrosis N: 11 cm x 7 cm x 5 cm)

9. What is the significance of the report "Both kidneys illustrate hyperechogenicity" How does evaluation of
echogenicity help in the diagnosis?
Echogenicity. (Normal  Korteks: hypoecoic, Pelvis: hyperecoic, Echogenicity dapat menentukan akut/ atau khronik )

10. What evidence in renal ultrasound will suggest obstruction?

 Large kidney
 Dilated calyses
 Dilated ureter

11. Is the cause of this patients renal failure acute or chronic? How did you arrive at that conclusion?
Acute : Short duration and rapid rise of BUN and creatinine.
Chronic : Long duration of BUN and creatinine elevation, Hemoglobin is low, Calcium and Parathormone disturbance

12. What is the calculated GFR?

(140- age) x BB (kg) (140- 41) x 76,5

GFR= = = 6,574 ml/min ~ 6,6 ml/min
72x creatinine serum 72x 16

13. What would be the calculated GFR in this case if the patient was female?
(140- age) x BB (kg) x 0,85 (140- 41) x 76,5 x 0,85
GFR= GFR (male) x 0,85 = 72x creatinine serum = 72x 16 = 5,588 ml/min ~ 5,6 ml/min
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Females have less muscle mass per kilogram than males.

14. What are the modalities treatment for the patient? Please explain the advantages and disadvantages of each
 Renal transplantation
+) Tidak dialysis, restriksi diet menurun, pasien merasa lebih sehat
-) Waktu tunggu lama (untuk donor yang meninggal), kemungkinan graft rejection, resiko saat operasi, butuh obat setiap
hari (steroid cushing syndrome), rawan infeksi.
 Hemodialisis
+) Terapi dilakukan oleh tenaga keshatan, tidak dilakukan setiap hari (3x/minggu), tidak membutuhkan alat di rumah
-) Membutuhkan asisten kesehatan untuk memasukkan alat, ke rumah sakit 3x seminggu pada jadwal ketat, retriksi cairan
dna diet, resiko infeksi, kemungkinan ketidaknyamanan (pusing, mual, keram kaki)
 Perytoneal dialysis
+) Terapi dialysis berlangsung terus (tidak berkala), terapi berkelanjutan dapat disesuaikan dengan gaya hidup terapi dan
dapat dilakukan saat sedang tidur
-) Harus ke rumah sakit setiap hari untuk mengganti alat, resiko infeksi, kateter permanen, butuh alat di rumah.