Download - Chronic Kidney Diseases, DM and GERD
Duty Report Chronic Kidney Diseases, DM
and GERD :Approach of complexity problem
Supervisor : Dr .dr. Soroy Lardo, Sp.PD FINASIMIrnanita Pratiwi
Maharani Falerisya NDivision Infectious Diseases and Tropical Medicine
Department of Internal Medicine Indonesian Army Central Hospital Gatot Soebroto
Faculty of Medicine UPN Veteran Jakarta
Patient’s Identity
• Name : Tn. T• Age : 69 y.o• Address : Jalan Kayu Manis Baru Jaktim• Job : Army• Married
Anamnesis
• Chief Complaint :Burning sensation and pain in abdominal since
one day before hospital
History of recent illness • Patients was feel burn sensation and pain in abdominal since
a day before come to the hospital. The pain spread to the back, abdomen to the right inguinal. The pain was persistent
• Patient also feel weekness since a day ago and feel his leg swollen for this recent 1 month.
• Nausea and vommite (-), headache (-), Fever (-), Bloated (-), Dispnea (-), Palpitation (-)
• Urinate rarely, there’s no urine colors changes, no micturition pain
• normal defecation
Past illness history
• Patient have diabetic and hypertension history since 5 years ago, he routinely check his illness to the internist. The doctor routinely check the renal function and found his creatinin serum was increase since 5 months ago, from 4 to 7.6 mg/dl
• The doctor recommend him for doing a hemodialisa
• 5 month ago he was hospitalize for a vertigo
TREATMENT HISTORY• Amlodipine 1 x 5 mg• Glurenorm 30 mgFAMILY HISTORY• No one in his family with similiar problem• No history of Hypertension, Diabetic , Allergic
HABITS Smoking 1 pack a day since 20 years old until
50 years old
Physical Examination • General state : moderate illness• Consiousness : Compos Mentis• Vital Sign Blood Pressure : 150/70 mmHgPulse : 80 x /minute, regularTemperature : 37,0oCRespiration Rate : 18x/minute
Body Weight : 77 kgBody Height : 172 cmBMI : 26 (Obesse I, Asian – Pacific perspective)
• Head : Normocephal, normal head distribution• Eye : Pale Conjungtiva +/+, Sclera icteric -/-• Ear, Nose, Throat : no abnormalities• Mouth : Acetonic smell (+), Less oral hygine, pale muccosal (-)• Neck : on CDL in regio colli dextra, lymph node enlargement (-)• Thorax : Lungs
Inspection : normal chest shape, Symmetric while breathing, no retraction of intercostae spacePalpation : symmetric tactile fremitus, symmetric chest expansion Percussion : Resonant sound bilateraly (sonor)Auscultation : Vesicular breathing sound bilaterally (+), Rhonki (-), Wheezing (-)
• Heart :Inspection : No visible ictus cordisPalpation : Ictus cordis at ICS 5 linea midclavicula sinistraPercussion : -Left margin : ICS V linea left midsternalis-Right margin : ICS V linea left mid clavicle -Upper margin : ICS IV linea left parasternal Auscultation : Normal S1-S2 are heard, murmur (-), Gallop (-)
• Abdomen : Inspection : normal countour, caput medusa (-)Auscultation : normal bowel movementPalpation : no palpable liver and spleen,no pain when palpating all abdomen region, normal turgorPercussion : tympanic in all area, Shifting dullness (-)
Extremitas : warm acral, Pretibial pitting edema (+/+), CRT <2s
Laboratory Findings Complete blood tests Result Normal value
Hemoglobin 9,9 g/dl ↓ 12,0 - 16,0
Hematocrit 29 % ↓ 37,0 - 47,0
Erythrocyte 3,3 ↓ 4,30 – 6,0 juta
MCV 89 fL 80,0 – 96,0
MCH 30 g 27,0 – 32,0
MCHC 34 g/dl 32,0 – 36,0
Thrombocyte 150.000 150.000- 400.000
Leukocyte 13.030 ↑ 4800 – 10.000Diff count
Basophyle 0 0 - 1
Eosinophyle 0 1 – 3
Neutrophyle 79% ↑ 50 – 70
Limfocyte 10 % ↓ 20 - 40
Monocyte 7 % 2 - 8
Blood metabolic
Ureum 154 mg/dl ↑ 20 – 50Creatinin 10,6 mg/dl ↑ 0.5 – 1.5Glucosse 245 mg/dl ↑ 70 - 100
Electrolyte
Natrium (Na) 138 135 - 147Kalium 3.8 3.50 – 5.00Chloride 108.0 95.0 – 105.0
Urinalisis Result Normal Value
Color yellow yellow
Clearness Clear Clear
Berat Jenis 1,025 1,000 – 1,030
pH 5.5 5.0 – 8.0
Protein ++ negatif
Glucosse + negatif
Keton - Negatif
Blood +++ ( 250RBC/ul) Negatif
Bilirubin - negatif
Urobilinogen 0.1 0,1 – 1,0mg/dl
Nitrit - negatif
Leukocyte esterase - negatif
Leukocyte 1-1-1 <5 / LPB
Eritrocyte 1-2-2 <2 / LPB
Silinder Butir 0-1-0 -
Cristal - negatif
Resume • Patients was feel burn sensation and pain in abdominal since a day
before come to the hospital. The pain spread to the back, abdomen to the right inguinal. Patients also feel weekness since a day ago and feel his leg swollen.
• Nausea and vommite (-), headache (-), Fever (-), Bloated (-), Dispnea (-), Palpitation (-), Urinate rarely , defecation normal
• Patient have diabetic and hypertension history, he routinely check the illness to the internist. The doctor routinely check the renal function and found his creatinin serum was increase since 5 months ago, from 4 to 7.6 mg/dl. The doctor recommend him to doing a hemodialisa
• Phsycial examination shows anemic conjungtiva, asetonic smell, CDL on right colli region, Pretibial pitting edema bilateral
• Laboratory found decrease of Red blood cell component, Increase ureum and creatinin serum
Problem list
• Burning sensation ec susp GERD • Abdominal Pain e.c susp. Urinary Tract Stones
dd/ UTI• Chronic Kidney Dissease• Hypertension• Diabetes Mellitus Type 2
Problem Solving
1. Burn sensation ec susp GERD dd Diabetic Gastropathy
• An : burn sensation since a day before hospital. Nausea and vommite (-), diarrhea (-)
• PE : abdomen auscultation : normal bowel movement, palpation : pain (-)
• Diagnostic : endoscopy• Th : • Education : avoiding large meals and spicy food
2. Abdominal Pain ec urinary track stones dd UTI• An: Abdominal pain spread to the back,
abdomen to the right inguinal• PE : Palpating pain (-)• Lab : Proteinuria ++, Hematuria +++• Diagnostic : Lumbal Xray AP Lateral
Chronic Kidney Disease• An : History of Diabetic Mellitus since 5 years ago,
Hypertension since 5 years ago, Urinate rarely , swollen leg• PE : Conjungtiva anemis, Asetonic smell, Pitting edema• Lab : decrease Red Blood cel component, Increase Ureum
and creatinin level
• Planning : blood gass analysis, Albumin
• Th : Hemodialisa
3. HypertensionAn : history of Hypertension and drug history of Amlodipine 2x5mgPE : BP : 150/70 mmHgTh: Amlodipine 5 mg
• Diabetic MellitusAn : History of DM since 5 yearsLab : GDP 245 mg /dlTh: Glurenorem
Burn Sensation in abdominal
• Clinical manifestation physical laboratory :- Burn sensation examination - hb : 9.9 g/dl - Pain - pale conjungtiva - leukocyte : 13.030 • Severity - aceton smell (+) - urea : 154- Clinical manifestation - CDL on regio coli - creatinin : 10.6- Swollen leg - pretibial pitting edema - blood gluccose 245• Commorbid disease - DM urinalisis - Hipertension - protein : ++• Past history - blood +++- DM - gluccose : +- Hipertension - ECG• Social history - chest x ray- Smoking 1 pack a day for 50 years(brinkman index = severe)
How Diabetes Mellitus affects the renal function