ckd hipertensi rey
TRANSCRIPT
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CASE REPORT:Chronic Kidney Disease ec. Hypertensive Nephropathy
Rey Jauwerissa030.07.215
Lecturer : dr. Arif Gunawan, Sp.PD
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Identity•Mr. WName •60 years oldAge •MaleSex•Sukamulya 02/02 KarawangAddress •LabourOccupation
•MoeslemReligion•MarriedMarital Status
•2 February 2012Date of Admission
•RengasdengklokTaken from
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Picture Taken February 7th 2012
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Main Complaint
Dyspnoe since 3 hours before hospitalized
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swelling nausea
vomiting
Headache
FatigueLoss of
appetite
Additional Complaints
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Mr W, a 61 years old man, came to RSUD Karawang emergency
room departement unit, due to dyspnoe since 3 hours before
hospitalized. The dyspnoe appeared suddenly, and became
worsen if he got layed down, and it got better in sitting position.
He also felt pulsative headache since 1 week before
hospitalized, which is located in the posterior part of head and
neck. Nausea and vommiting was also present, contained
recently eaten food, without any blood seen, and it was not
coffe-like coloured.fatigue and loss of appetite was also present.
History of present illness
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One week before hospitalized he felt
swollen on all over his bodies, and mainly seen
on the face and both extremities. He denied had
any fever, cough and chess pain, stomache and
low back pain. He ussualy deffecated once a day,
solid consistency, without blood and slime. He
urinate yellow to colourless, clear, Without blood
and no pain
History of present illness
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Patient never had the same symptoms before Hypertension (+) since 5 years ago, not
controllable DM (-) Food or drugs allergy (-) Cardiovascular disease (-)
Pulmonary disease (-) Liver disease (-) Gastrointestinal disease (-) Never been operated before
History of past illness
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• Same illness before (-)• DM (-)• Hypertension (-)• Asthma / Allergic (-)• Cardiovascular / pulmonary disease (-)
History of family illness
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Personal and Social History
Smoked history (+), 3 cigarettes a day Medication (-) Never drank any alcohol before Didn’t exercise regularly
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PHYSICAL EXAMINATION
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General appearance Moderately ill
Conciousness Compos mentis
Weight / Height 55 kg/160 cm
BMI 21,48
General Condition
General
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Vital sign
Vital Sign
General
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Head◦Normocephaly
Eyes◦Conjunctiva anemic (+/+)◦Sclera icteric (-/-)
Neck Lymph gland is not palpable Thyroid gland is not palpable JVP 5-2 cmH2O
Physical Examination
Head and Neck
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• Inspection : Symmetrical movement of thorax
• Palpation : Symmetrical vocal fremitus
• Percussion : Sonor of bilateral hemithorax
• Auscultation : Vesicular breath sound in
both lungs, no ronchi and wheezing
Lung Examination
Thorax
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• Inspection : Ictus cordis is not visible• Palpation : Ictus cordis is palpable at 5th ICS 1
cm medial of LMCS• Percussion : no heart enlagement • Auscultation: Regular I - II heart sound
no murmur and gallop
Heart Examination
Thorax
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Inspection : ◦ Flat abdomen
Palpation : ◦ No abdominal pain◦ No liver and spleen enlargement
Percussion :◦ No pain present on abdominal percussion◦ Sounds tympani
Auscultation :◦ Bowel sound 4x/minute
Abdominal Examination
Abdomen
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Extremity Examination
+ ++ +
•Warm acrals
•Oedema+ ++ +
Extremity
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Laboratory ExaminationFebruary 2th 2012
Hb 4,3 12 – 17 g%
Leukocyte 12.200 5 – 10 rb
Trombocyte 220.000 150 – 450rb
Ht 14 37 – 48 %
Basofil 0 0 - 1
Eosinofil 0 1 - 3
Basil 0 2 - 6
Segmen 83 40 - 70
Lymphocyte 13 20 - 40
Monocyte 4 2 – 8
GDS 132 80 – 140 mg/dl
Ureum 247,1 10 – 45 mg/dl
Creatinine 15.05 0,4 – 1,5 mg/dl
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Cockroft-Gault Formula
Creatinine Clearance
(140 – age) x Weight
Cr Serum x 724.06
February 2th 2012
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Electrocardiography
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ResumeSymptoms Signs Laboratory
and others• Dyspnoe (+)• Swelling (+)• Nausea and vomiting• Headache• Fatigue• loss of appetite
• BP: 210/100 mmHg• HR: 100 x/minute• T: 36,5oC• RR: 32 x/minute• Eyes : CA +/+• Oedem in both
extremities
• Hb 4,3 g%•Leukocyte 12.200• Ht 28 %• Ureum 247,1 mg/dl • Creatinin 15,05 mg/dl
•Creatinine Clearance 4,06
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Chronic Kidney Disease ec hypertensive nephropathy
Chronic Kidney Disease ec. Nephrotic syndrome
Chronic Kidney Disease ec. Acute glomerulo nephritic
Acute kidney injury
Differential Diagnosis
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Chronic Kidney Disease ec hypertensive nephropathy
Working Diagnosis
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Chest X-ray Blood gas analysis Urinalysis Abdominal USG
Suggested Examination
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Bed Rest High calories, low protein diet IVFD D5% 10 drops/min Prc transfussion Renxamin 1 fl / day Lasix 2 x 1 amp CaCO3 3x1 tab Asam folat 3x1 tab Captopril 25 mg 3x 1 tab Valsartan 1x 8 mg tab Amlodipin 1x1
Treatment
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PRO- Hemodialysis
Suggested Treatment
PATIENTREFUSED
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Ad Vitam Dubia ad bonam
Ad Functionam Dubia ad malam
Ad Sanationam Dubia ad malam
Prognosis
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