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MORNING REPORT

CASE

Oktober 9th 2014

PATIENTS
IDENTITY
Name : IWB
Age
: 70 yo
Gender : male
Status : Married
Religion : Hindu
Address : Salemadeg, Tabanan
Tc
: 7 oktober 2014 13.00

ANAMNESIS
(Heteroanamnesis)

Chief complain :

body weakness
Present history :
Patient came to the emergency unit
BRSU Tabanan with chief complain body
weakness. Patien complain weakness 3
days BATH weakness fell all over the
body he cant do any activity. Patien also
complain nausea since 3 days BATH. This
complain cause the patient cant eat.

Contd

He also felt nausea without vomiting


since 3 days. It felt almost everyday
and it worsen by food consumption
and he also complain loss of
appetite.
Fever, headache, shortness of
breath was denied
Urination and defecation were said
to be normal. Bloody urine, pain
since urinating and blackish stool

Past illness history

History of the same complain was


denied by the patient. patients had a
history of taking medication arthritis for
10 years, but the patient forgot the
name of the medicine and patients had
a history of gastritis
History of DM, hipertension, heart
disease was denied.

Family history :

None of the family member had the same


complained as the patient
History of HT, kidney, GI Tract and DM was
denied

Social History :

Patient is a farmer. He consumption of


cigarettes since young . now he smoke 2
cigarettes per day. Consumption alkohol was
denied

PHYSICAL EXAMINATION
General appearance
: Moderately ill
Level of consciousness :Compos Mentis
GCS
: E4V5M6
Vital Sign:
BP : 100/60 mmHg
RR : 20 x/min
PR : 104 x/min
t
ax : 36C
Weight : 55 kg
Height
: 165 cm
BMI
: 20,20 kg/m2

Eyes : anemis(+/+); icterus (-/-);


Rp +/+ isocoric, oedema palp.
(-/-)
ENT : Tonsils T1/T1; pharyngeal
hyperemia (-); tongue normal; lip
cyanosis (-)
Neck : JVP RP + 2 cmH2O;
lymph node enlargement (-)

Thorax : Simetris, retraction (-)


Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis not palpable
Percussion :
LB
: at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric
Palpation : VF N/ N
Percussion : sonor/sonor
Auscultation : Ves + / + , Rh -/-, wh -/-

Abdomen :
Inspection
: Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion
: Tympani
Palpation
: Tenderness on palpation (+)
on
epigastium; liver & spleen not
palpable
Ballotment (-/-)
Extremities: Warm +/+; edema -/+/+
+/+

Complete blood count


Paramet
er
WBC

Result

Unit

Remarks

Reference
range

25.2

103/L

4-10

47,00 80,00

-Ne

85,5%

21.5

103/L

-Ly

10,4%

2.6

103/L

13,0 40,0

-Mo

3.63%

0,919

103/L

2,00 10,00

-Eo

0.06%

0,015

103/L

0,00 5,00

-Ba

0,451
%

0114

103/L

0,0 0 2,00

RBC

3.33

106/L

4,50 5,50

HGB

9.2

g/dL

13,00 16,00

HCT

30

40,00 48,00

MCV

90.0

fL

80,00
100,00

MCH

27.7

pg

26,00 34,00

MCHC

30.8

g/dL

32,00 36,00

Blood chemistry panel


Parameter

Result

Unit

Remarks

Reference
range

SGOT

U/L

SGPT

17

U/L

0-50

BUN

34

mg/dL

8-18

Creatinine

2.2

mg/dL

0,60 1,10

Glukosa

111

mg/dL

74-106

Natrium

138

Mmol/
L

135-155

Kalium

5.4

Mmol/
L

3,5-5,5

Chlorida

106

Mmol/
L

0-50

95-105

ECG

sinus tachycardia (104 x/minute)

ASSESMENT

Mild anemia normokromik normositer


Leukositosis
Chronic kidney disease stage IV

PLANNING

Therapy

Hospitalized
IVFD NaCl 0.9% 20 drops/mnt
Caftriaxone 2x 1gr
Folic acid 2x1 tab
Pantoprazole 1x1 tab
Ondansentron 3x4mg

Pdx
-

Monitoring

Vital sign
Complaints

THANK YOU

Criteria :
1. Kidney damage for 3 month
structural and functional abnormality
with or without decreased Glomerular Filration
Rate (GFR)
manifest by either abnormality of :
pathology
blood composition
urine composition
imaging test
2. GFR < 60 ml/min for 3 month, with or without kidney
damage

Explanation :
Structural abnormality e.g. single kidney,
kidney/ureter stone, cystic kidney,
proteinuria
Prostate hypertrophy, etc
GFR : calculated by Kockroft Gault Formula
Blood composition e.g. ureum, creatinin
Urine composition e.g. proteinuria, haematuria
Imaging e.g. BNO (plain photo abdomen), USG etc

Kidney disease 3 month :

GFR (Cockroft Gault)

< 60 ml/mnt/1.73 m2
- CKD

60 ml/mnt/1.73 m2

Kidney damage (-)


- normal

Kidney damage (+)


- CKD

STAGES OF CKD: A CLINICAL ACTION PLAN


Stage

Description

GFR

Actions*

(mL/min/1.73 m2)

Kidney damage with

90

Diagnosis and treatment. Treatment of


comorbid conditions, Slowing
progression, CVD risk reduction

60-89

Estimating progression

normal or GFR
II

Kidney damage with mild


GFR

III

Moderate GFR

30-59

Evaluating and treating complications

IV

Severe GFR

15-29

Preparation for kidney replacement


therapy

Kidney failure

< 15 or dialysis

Replacement (if uremia pesent)

Chronic Kidney Disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m2 for 3
months. Kidney damage is defined as pathologic abnormalities or markers of damage, including
abnormalities in blood or urine test or imaging studies
* Includes actions from proceeding stages

ETIOLOGY OF CKD
Etiology of CKD are :
1.

Diabetes Mellitus

2.

Chronic Glomerulonephritis

3.

Chronic Pyelonephritis

4.

Hypertension

5.

Urinary tract stone

6.

Obstruction (tumor, prostate)

7.

Immunological disease (SLE)

8.

Congenital (polycystic kidney)

9.

Malignancy

10. Others :
pregnancy
chronic liver disease

CLINICAL MANIFESTATION :

Symptom :

Not specific : - lethargic, weakness. nausea, vomiting, headache,


- edema, dyspneu on effort

Physical examination :

Hypertension, anemic, edema

Sign of complications e.g. heart hypertrophy, ascites

Patophysiology of hypertension in CKD


1. - Sodium retention
- fail of the kidney for excreted water and sodium
excess

2. - Acceleration of Renin Angiotensin System activity


- increased secretion of renin

Angiotensinogen
(produced by liver)
Renin
(produced by kidney

Angiotensin I

Angiotensin
Converting Enzyme
(ACE)
Suprarenal cortex

Angiotensin II

Aldosteron
Renin Angiotensin Aldosterone System

PATHOPHYSIOLOGY OF ANEMIA IN CKD


1. Erythropoitin insufficiency
- decreased of erythropoitin secreted by the kidney
2. Iron deficiency
- chronic bleeding
- low intake
3. Others
- haemolysis / decreased of erythrocyte live spend
- depressed of bone marrow by uraemic substances

Patients with chronic kidney disease should be


evaluated to determine:
1. Diagnosis (type of kidney disease)
2. Comorbid conditions;
3. Severity; assessed by level of kidney function;
4. Complications, related to level of kidney function;
5. Risk for loss of kidney function;
6. Risk for cardiovascular disease

COMPLICATION OF CKD
1. Cardiac diseases
- coronary artery disease
- congestive heart disease
- acute left heart failure
2. Metabolic acidosis
3. Electrolyte imbalance
- hyper / hypokalemia
- hyper / hyponatremia
4. Renal osteodystrophy (renal bone disease)

Early detection of CKD using kidney health check


Who is at higher risk
of kidney disease

What should be
done

How often

Age > 50 Years

Blood pressure

Every 12 months

Diabetes
Smoking

Urine dipstick
(mircoalbuminuria if
diabetes present)

Obesity

eGFR

High Blood Pressure

Family history of
kidney disease

Treatment for chronic kidney disease should include:


1. Specific therapy, based on diagnosis
2. Evaluation and management of comorbid conditions;
3. Slowing the loss of kidney function
4. Prevention and treatment of cardiovascular disease;
5. Prevention and treatment of complications of decreased
kidney function
6. Preparation for kidney failure and kidney replacement
therapy;
7. Replacement of kidney function by dialysis and
transplantation, if signs and symptoms of uremia are
present