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

DAFTAR MASALAH
NO
1
ACTIVE PROBLEMS DATE NO PASSIVE PROBLEM DATE

Stage V Chronic kidney Disease with Hyperkalemia

25/03/2011

Stage II Hypertension with LVH

Normochromic Normocytic Anemia

25/03/2011

25/03/2011

ANAMNESIS March 25 2011 at C3C ward

Chief Complaint: Weakness
12 days ago Weakness (+), gradually, all day long, daily activity disabled

OTHER SYMPTOMS
Positives
1. 2. 3. 4. 5. 6. Dizziness Tiredness Loss of appetites Palpitation Swollen leg Less micturition (1,5 glass/day) 1. 2. 3. 4. 5. 6. 7. 8. 9.

Negatives
Fever Blurred vision Cough and influenza Epistaxis Vomiting Gastric pain Cachexia Low back pain Painful micturition

ANAMNESIS March 25 2011 at C3C ward

Chief Complaint: Weakness
12 days ago Weakness (+), gradually, all day long, daily activity disabled

2 days ago HD needed Patient was reffered

RSDK
10 days at RS Kartini Blood lab, Chest X-ray Ultrasound

MEDICAL HISTORY
History of hypertension for 18 years, uncontrolled, medication taken but the patients couldnt 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 mmHg Pulse: 82 x/min RR: 20 x/min Temp: 37oC Anthropometry assessment BW: 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 symetric Rate 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 FINDINGS
Haematology
Hb (g%) Ht (%) RBC (10 6 /mm3) MCV (fl) MCH (pg) MCHC (g/dl) WBC (10 3 /mm3) Platelets (10 3 /mm3) Findings:

Normal Range
14 18 40 - 48 (-) (-) (-) (-) 5 10 150 400

23/03/11 RS Kartini
7.1 20.4 (-) (-) (-) (-) 8.7 270 Anemia

Normal Range
13 16 40 54 4.5 6.5 76 96 26 32 29 36 4 11 150 400

24/03/11 RSDK
8.30 24.5 2.90 84.40 28.50 33.80 7.20 224.0

25/03/11 RSDK
9.00 26.6 3.16 84.20 28.40 33.70 6.80 222.0

Normocythic Normocythic Normochro Normochro mic Anemia mic Anemia

Normal Range BGL (mg/dl) Ureum (mg/dl) Creatinin (mg/dl) Albumin Na+ (mmol/l) K+ (mmol/l) Cl- (mmol/l) Ca (mmol/l) 80 - 150 10 - 50

22/03/2011 RS Kartini 136 297.2 Bilirubin tot Bilirubin dir SGOT SGPT Gamma GT ALP Blood type

Normal Range 0-1 0 0.25 15 -38 9 42 11 61 64 644

23/3/2011 RS Kartini 0.59 0.15 34 36 28 191 B Rh (+)

0.8 1.2

10.2 136 7.1 9.6

136 - 146 4.4 4.8 8.1 10.4

Findings

Azotemia Hyperkalem ia

CREATININ CLEARANCE TIME Cockcroft-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, ECG Rx : - Valsartan 1 x 80 mg - Diltiazem 3x60 mg - Low Salt diet Mx : KU,TV Ex : 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 : -