Case Presentation

Razel F. Pencerga
OBJECTIVES
• To discuss the normal metabolism of Calcium
and Phosphorous
• To discuss what happens in the Calcium and
Phosphorous level in CKD patients
Name: D. N.
Age/Sex: 62/M
Civil Status: Single
Occupation: Priest
Date of admission: July 11, 2019
CHIEF COMPLAINT

BIPEDAL EDEMA
HISTORY OF PRESENT ILLNESS
• 3 Weeks Prior to Admission:
▫ had onset of bipedal edema
▫ complained of abdominal bloatedness
▫ admitted and discharged with improvement
HISTORY OF PRESENT ILLNESS
• 1 week Prior to Admission,
▫ abdominal distension and bloatedness
▫ not associated with dyspnea, vomiting, headache
▫ no medications taken
▫ patient tolerated the condition
HISTORY OF PRESENT ILLNESS
• 3 days Prior to Admission,
▫ bipedal edema and difficulty ambulating
▫ persistence of abdominal distension and
bloatedness
▫ not associated with dysnea, nausea, vomiting
▫ worsening of symptoms prompted the patient to
seek consult and subsequently admitted
PAST MEDICAL HISTORY
• 1997 – diagnosed with DM II (Metformin)
• 2018 – Hypertension and CKD
• March, May, June 2019 – admitted in this
institution
• No known food and drug allergies
 FAMILY HISTORY PERSONAL/SOCIAL HISTORY

• (+) Hypertension • (-) Smoker

>Mother and Father
• (-) Alcoholic
• (+) DM Beverage Drinker
>Mother
REVIEW OF SYSTEMS
• General • HEENMT
▫ (-) fever ▫ Head
▫ (-) chills  (-) syncope
▫ (+) fatigue  (-) headache
▫ (+) weight gain  (-) trauma
▫ Eyes
• Skin  (-) pain
▫ (-) rash  (-) blurring of vision
▫ (-) itching ▫ Ears and Nose
 (-) discharge
 (-) pain
▫ Mouth and Throat
 (-) sore throat
REVIEW OF SYSTEMS
• Neck • Gastrointestinal
▫ (-) pain ▫ (-) Nausea
▫ (-) stiffness ▫ (-) Vomiting
▫ (-) lumps ▫ (-) Loss of appetite
▫ (-) Constipation
• Respiratory • Genit0-urinary
▫ (+) cough ▫ (+) Nocturia
▫ (-) dyspnea ▫ (+) Polyuria
▫ (-) hemoptysis ▫ (-) Gross Hematuria
• Extremities
• Cardiovascular ▫ (+) pins and needle sensation
▫ (+) 2 pillow orthopnea in the upper and lower
▫ (-) chest pain extremities
▫ (-) palpitations
 PHYSICAL EXAMINATION
• Patient is awake, alert, coherent and not in
respiratory distress.

Result Result

Blood Pressure 130/90 mmHg Weight 89 kilos

Pulse Rate 66 bpm Height 5’6”

Respiratory Rate 19 cpm BMI 31.9

Temperature 36.4 oC O2Sat 98.99

PHYSICAL EXAMINATION
• SKIN:
▫ -brown-black discoloration noted in both lower
extremities, no scars, rashes and lesions noted,
pitting edema present in the lower exremities
PHYSICAL EXAMINATION
• HEENT
▫ Head- normocephalic, no assymmetry, non
tender, presence of engorged artery in the
temporal area(bilateral) with tenderness upon
palpation
▫ Eyes – no discharge and redness, anicteric sclerae,
pink palpebral conjuctivae, no erthyma,
periorbital edema
▫ Ears – no signs of inflammation, (-) tug test, no
discharges noted
PHYSICAL EXAMINATION
• HEENT
▫ Nose- septum in the midline, no discharges and
obstructions noted
▫ Mouth and Throat – moist lips and oral mucosa,
no enlargement of the tonsils

• Neck
▫ No neck vein engorgement, JVP 4cm
PHYSICAL EXAMINATION
• Chest and Lungs
▫ Equal chest expansion, no chest retractions and
use of accessory muscles
▫ Non tender upon palpation
▫ Dullness upon percussion
▫ Decrease breath sounds on both lung fields
PHYSICAL EXAMINATION
• Cardiac
▫ Adynamic precodium
▫ PMI noted in the 5th left intercostals space, no
heaves and thrills noted
▫ Regular rate and cardiac rhythm, no murmurs
heard
PHYSICAL EXAMINATION
• Abdomen
▫ No scars, masses and striae noted, distended
abdomen
▫ Normoactive bowel noted
▫ Dull upon percussion
▫ Soft and non tender, no rigidity, no guarding
PHYSICAL EXAMINATION
• Extremities
▫ Warm and moist, CRT <2 seconds, bipedal edema
grade III in both lower extremities
PHYSICAL EXAMINATION
• Neurologic Examination
CRANIAL NERVE OBSERVATION

I Able to smell

II Both pupils reactive to light

III, IV, VI EOM intact

V Able to clench jaw

No facial asymmetry, able to close both eyes against

VII
resistance
PHYSICAL EXAMINATION
• Neurologic Examination

CRANIAL NERVE OBSERVATION

VIII Able to hear in both ears using finger rub test

IX, X Able to swallow

Able to shrug both shoulders, can move head from side to

XI
side

XII No tongue deviation

PHYSICAL EXAMINATION
RIGHT LEFT
• Motor
5/5 5/5
5/5 5/5

• Sensory – decrease sensation felt on both lower

extremities
 LABORATORY DIAGNOSIS
6/18 6/19 06/27 06/22 07/11 07/13
CREATININE 907.9 882.8 869
TOTAL CALCIUM 1.82 1.78 1.88
PHOSPHORUS 2.78 7.40
IMPRESSION

• ANASARCA SECONDARY TO CHRONIC

KIDNEY DISEASE SECONDARY TO DIABETIC
NEPHROPATHY AND HYPERTENSIVE
NEPHROPATHY; HYPERTENSIVE
CARDIOVASCULAR DISEASE; DM TYPE II
DIFFERENTIAL DIAGNOSIS
• CHF
• LIVER CIRRHOSIS
• KIDNEY FAILURE
FINAL DIAGNOSIS

• CHRONIC KIDNEY DISEASE SECONDARY TO

DIABETIC NEPHROPATHY AND
HYPERTENSIVE NEPHROPATHY;
HYPERTENSIVE CARDIOVASCULAR
DISEASE; DM TYPE II
DISCUSSION
CALCIUM METABOLISM
PHOSPHATE METABOLISM
CHRONIC KIDNEY DISEASE

• Chronic kidney disease (CKD) encompasses a

spectrum of pathophysiologic processes
associated with abnormal kidney function and a
progressive decline in glomerular filtration rate
(GFR). The risk of CKD progression is closely
linked to both the GFR and the amount of
albuminuria.
 LABORATORY DIAGNOSIS
6/18 6/19 06/27 06/22 07/11 07/13
CREATININE 907.9 882.8 869
TOTAL CALCIUM 1.82 1.78 1.88
PHOSPHORUS 2.78 7.40
CKD