dr.

Mohammad Rifal
DEPARTMENT OF INTERNAL MEDICINE
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2018
 Menjadikan Bagian Ilmu Penyakit Dalam Fakultas Kedokteran
Universitas Hasanuddin sebagai pusat pendidikan yang
unggul, mandiri, dan bermartabat untuk menghasilkan dokter
spesialis penyakit dalam yang berkualitas dan mampu bersaing
secara regional, nasional maupun global, dengan didukung
oleh sumber daya manusia yang profesional dan bertanggung
jawab.
1. MELAKSANAKAN KEGIATAN PENDIDIKAN BERTARAF INTERNASIONAL YANG
BERBASIS KOMPETENSI DALAM UPAYA MENINGKATKAN DERAJAT KESEHATAN
MASYARAKAT.
2. MELAKSANAKAN PENDIDIKAN KEDOKTERAN YANG BERKUALITAS
INTERNASIONAL DALAM UPAYA PENGEMBANGAN ILMU PENGETAHUN DAN
TEKNOLOGI KEDOKTERAN.
3. MENGUPAYAKAN PENGEMBANGAN SUMBER DAYA MANUSIA UNTUK
MENUNJANG PENGEMBAGAN PENDIDIKAN DAN PENGABDIAN KEPADA
MASYARAKAT.
4. MENGHASILKAN DOKTER SPESIALIS PENYAKIT DALAM YANG BERPOTENSI
AKADEMIK DAN PROFESIONAL YANG MEMADAI, SERTA BERMODAL DAN
BERDEDIKASI TINGGI.
5. MENGHASILKAN DOKTER SPESIALIS PENYAKIT DALAM YANG MAMPU
MENYERAP, MENELITI, DAN MENGEMBANGKAN ILMU PENYAKIT DALAM
SESUAI DENGAN ILMU PENGETAHUAN DAN TEKNOLOGI.
6. MENGHASILKAN DOKTER SPESIALIS PENYAKIT DALAM YANG MAMPU
MENGEMBANGKAN ILMU KESEHATAN DALAM BERBAGAI JENJANG
PENDIDIKAN DALAM PENINGKATANTARAF DAN KUALITAS HIDUP
MASYARAKAT.
 PATIENT IDENTITY

 Name : Mr. S J Hospital : RSWS

 Age : 52 years Room : L1AB room 6 bed 1
 Address : Kendari Medical Record : 83 04 68
 Occupation : entrepreneur Date of Admission: 17/01/2018(06.10)
 Religion : Katolik Date of Death: 30/01/2018 (06.15)
 Ethnic : Toraja Doctor on duty: dr. Moh Rifal
 Marital status : Married Chief Doctor: dr. Nur Rahmah Musa
Chief complain : Weakness
Present history:
Experienced since 2 weeks ago, gradually getting heavier since two days before hospital admission.
Less feed intake in the last 1 week, no bleeding, no bleeding history present, Previously hospitalized
at Kendari Hospital for 1 week and diagnosed with kidney failure, had transfusion PRC 4 pouch and
administered telmisartan drug 80 mg once in day. Then, The patient was referred to RS Wahidin
Sudirohusodo with a hemodialysis plan.
Nausea since 1 week ago, no vomiting, history of vomiting experienced 1 week ago, no epigastrium
pain. No fever, no fever history, no headache, no cough, no long cough history, no shortness of
breath, no chest pain, no chest pain history.
Yellowish micturition present, normal volume, history of sandy urination 2 years ago,
history of bloody urination did not exist.
Brownish yellow stools, soft consistency, a history of black defecation does not exist,
a history of bloody defecation does not exist.
Patients often complained about the pain on both of his knee that induced by activity
and occasionally got stiff joints in the morning, but usually not more than 30 minutes,
but no current joint pain present for now, no back pain, no history of pelvic pain.
 History of hypertension is known since 2 years ago, but not routinely taking
medicine.
 A history of high uric acid has been experienced for more than 10 years. Patients
taking Allopurinol 1x100 mg drug routinely from the last 3 years .The history of
swelling and pain on the big toe is present and at the first time attack, was felt more
than 10 years ago, and since then it has often been felt repeatedly.
PAST MEDICAL HISTORY
 History of previously Diabetes Mellitus did not exist
 No history of heart problems

FAMILY HISTORY
 The same family history of a complaint does not exist
 There is no history of DM and hypertension in the family
 There is no history of kidney disease in the family.
PSYCHOSOCIAL HISTORY
 Job history: Entrepreneur
 Education history: Elementary school
 Allergy history: None
 Immunization history: Unknown
 Sports: Nothing
 Specific Food Habits: Nothing special
 Smoking: Never
 Drugs: Never
 Alcohol: Never
GENERAL DESCRIPTION
 Illness: moderate pain
 Nutritional Status: Adequate Nutrition
 Awareness: Glasgow Coma Scale 15 (E4M6V5)
 Weight: 67 kg
 Height: 160 cm
 IMT: 26 kg / m2

VITAL SIGNS
 Blood pressure: 150/90 mmHg
 Pulse: 84 times / minute
 Respiratory: 22 times / minute
 Temperature: 36.7 oC (axilla)
PHYSIC EXAMINATION
 Head: normocephal, black hair, hard to remove.
 Eyes: conjunctival anemis exists, no jaundice sclera, palpebra edema is not
exist, isokor pupil diameter 2.5 mm / 2.5 mm, RCL (+), RCTL (+)
 Mouth: dry mouth does not exist, no dirty tongue, tonsils and pharynx are not
hyperemic
 Neck: no stiff neck, DVS R + 1 cm H2O, no deviation of trachea, no enlargement
of lymph nodes
Thorax:
Pulmo
 I: symmetric impression of both left and right
 P: symetric fremitus vocal on both of left and right
 P: sonor on both lung fields
 A: vesicular breathing sounds, no rhonchi and wheezing
Cor:
 I: Ictus cordis is not visible
 P: Ictus cordis palpable on ICS V Sinistra
 P: Right upper upper heart limits on ICS II Linea parasternalis dextra, Lower right heart
margin on ICS IV Line parasternalis dextra, The upper left heart border of ICS II Linea
the sternalis sinistra, Lower left heart margin in ICS V Linea medioclavicularis sinistra
 A: Pure I / II heart sound is regular, gallop does not exist, no noisy
Abdomen:
 I: flat, follow motion of the breath, tumor mass does not exist
 A: intestinal peristaltic (+) in a normal impression
 P: no tenderness, liver and spleen are not palpable.
 P: timpani, ascites does not exist.
Extremities:
 Superior: Udema no, capillary refill time> 2 seconds, warm acral
 Inferior:
 Genu dextra: No udema, no rubor, heat, dolor and limited range of movement, no
crepitation.
 Genus Sinistra: No udema, no rubor, heat, dolor and limited range of movement,
crepitations exist.
 The pedis dextra region: tofus (+) in MTP 1 and medial malleolus.pretibial edema does
not exist, no udema dorsum pedis, capillary refill time> 2 seconds, warm akral.
 06.30

WBC 7.96 (10^3/uL)

Hb 8,5 g/dL
RBC 2,76 (10^6/uL)
PLT 330.000/uL
HCT 24,9%
MCV 90,2 fl
MCH 29,0 pg
MCHC 32,1 g/dL
Neut 72,1 %
Lymp 16,7 %
GDS 85 mg/dL
Ureum 352 mg/dL
Creatinin 26,74mg/dL
Na 132 mmol /L
K 6,0 mmol /L
Cl 95 mmol /L
PT 10,9
APTT 37,6
INR 1,00
SGOT 40
Urinalisis 17-01-2018
06.30

Protein 3+

Glukosa -

Sedimen eritrosit 7+

Sedimen leukosit 4+

Bakteri 1
EKG:17-01-2018 (06.30):
Sinus rhythm, HR 80x / min, normo axis, P wave 0.04 seconds in lead II, normal PR interval (0.18 seconds), QRS
complex normal (0.10 sec), ST segment isoelectric

Figure 1. EKG
Thoraks AP Photo (17-01-2018)
Photo thoraks AP (less inspiration):
 Insertion DLC on hemithorax dextra via subclavicula with an impression tip on the
right atrium
 Cor impressive impression, CTI> 50%
 Both sinuses and diaphragms are good
 Normal bronchovascular
 Intact bones
 Soft tissue looks good
Impression:
 Insertion DLC with tip impression on the right atrium
 Cardiomegaly
USG Abdomen
 Hepar: the size and echo of the parenchyma in normal limits. Sharp tips, regular
surface, no visible vascular dilatation and extra bile duct / extrahepatic. SOL isn’t
visible
 GB: walls are not thickened, regular mucosa. echyo rock / SOL isn’t visible
 Pancreas: the size and echo of the parenchyma in normal limits, SOL does not appear
 Lien: the size and echo of the parenchyma within normal limits, SOL does not appear
 Right kidney: enlarged, echo corticomedullary thinning, visible dilated PCS. echo rock
/ SOL does not appear .
 Left kidney: enlarged, echo corticomedullary thinning, dilated PCS appearance. echo
rock / SOL. does not appear
 VU: difficult to evaluate (minimal urine)
 No visible echo of free fluid in the peritoneal cavity
 Impression: Bilateral Hydronefrosis
1. Gout nephropathy dd G5A3 obstruction
Thought on the weakness as the basis complaints accompanied by nausea since last 1 week. The history of gout
experienced more than 10 years ago. The history of sandy urination, on the physical examination found tofus on
MTP 1 and medial dextra malleolus. From the investigation was obtained ureum 352, cretainin 26,73 with GFR
EPI 2 ml / mnt / 1,73, abdominal ultrasound showed bilateral hydronephrosis and uric acid 16.
 Diagnostic plan: -
 Plan therapy:
1. Low sodium diet <2 grams / day
2. Low protein diet 0.6 gram / KgBB / day
3. Low-potassium diet, purine, phosphate
4. Amino acids essensial 250 cc / 24h / intravenous
5. Ondansetron 4 mg / 8jam / intravena
6. Hemodialysis (agree)
7. Preparation Hemodialysis examination marker virus: HBsAg, anti HCV, HIV
8. Installation of BTKV Consumers Hemodialysis access for DLC insertion
9. Plan monitoring:
10. Monitoring the awareness and vital signs
 Educational plan: Explain about the disease, examination plan, therapy, complications, and prognosis of the
illness suffered by the patient.
2. Hyperkalemia
 Thought based on the laboratory results showing potassium 6
 Diagnostic plan: -
 Plan therapy:
1. Low potassium diet
2. Ca polystyrene sulfonate 5 gram / 8hours / oral
 Plan monitoring:
1. Evaluate signs of arrhythmias
2. Electrolytes and ECG
 Educational plan: explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient
3. Normocytic normocytic anemia.
Thought on the weakness as the basis complaint accompanied by an anemic
conjuncitva. From the laboratory examination found Hb 8,5, MCV 90, MCH 29.
Anemia that occurred in this patient is suspected an renal anemia. However, further
examination is needed to determine other causes of anemia
 Diagnostic Plan: Fe, TIBC, Ferritine, ADT
 Plan therapy: -
 Plan monitoring: Hemoglobin
 Educational plan: Explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient
4. Hipertensi grade 1 (JNC 7)
Thought based on the hypertension hystory since the last 2 years, consumption of
telmisartan 80 mg. From physical examination obtained TD 150/90 mmhg.
 Diagnostic plan: -
 Plan therapy:
1. Low sodium diet <2 grams / day
2. Amlodipine 10 mg / 24h / oral
3. Telmisartan delay
 Plan monitoring: Blood Pressure, target <150/90 mmhg
 Educational plan: Explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient.
5. Chronic arthritis Gout with tophus
Thinking based on the gout history that has been > 10 years, since that time the pain
and swelling of the toes often recurs. on physical examination of pedis dextra found
tofus on MTP 1 and medial malleolus, uric acid 16.
 Diagnostic plan: Uric acid / 24 hours
 Plan therapy:
1. Low purine diet
2. Allopurinol 100 mg / 48 hours / oral
 Plan monitoring: -
 Educational plan: explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient
6. Osteoarthritis genu sinistra
Thinking based on the patient age 52 years with a history of frequent knee pain that
is affected by activity, on physical examination found crepitation on genu sinistra
 Diagnostic plan:
1. Photo X-ray Genu sinistra
2. LED
 Plan therapy: -
 Plan monitoring: Clinical Symptoms
 Educational plan: Explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient
7. Bilateral hydronefrosis

Thought based on the abdominal ultrasound results with bilateral hydronephrosis.

 Diagnostic plan: -
 Plan of therapy: Consul Ts. Urology
 Plan of monitoring: Clinical symptoms
 Educational plan: explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient.
8. Urinary tract stone Suspects

 Thinking based on the history of sandy urination on 2 years ago, urinalysis of blood
10+, erythrocyte sediment 7 and bilateral hydronephrosis in abdominal ultrasound.
 Diagnostic plan: Abdominal MSCT non contrast
 Plan of therapy: Consul Ts. Urology
 Plan of monitoring: Clinical symptoms
 Educational plan: Explain about the disease, examination plan, therapy,
complications, and prognosis of the illness suffered by the patient
date History of illness therapy
BTKV S: Post double lumen insertion Therapy
17-01- O: Moderate pain, E4V5M6. TD: 190/70 - Ceftriaxone 1 gr/12
2018 N: 80x / min, R: 20x / min, S: 36.5C hours/intravena (1)
20.15 In subclavicula dextra mounted - Wound care / 3 days
double lumen patent - Hemodialysis
A: Obstructive nephropathy post Plan of monitoring:
double lumen catheter mounting DAY- - Vital sign and general
0 status observation
- Photo control of X-ray
thorax
Interna S: Patients complain of weakness, no nausea, less appetite, had attached Therapy:
18/01/2018 HD access right on the back. Low protein diet 0.6 gr / KgBB / day
06.00 O: TD: 140/80, N = 88x / min, temperature = 36.7, respiration 20x / min Low sodium diet <2 g / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low purine, potassium, phosphate diets
Neck: JVP R + 1 cmH20 Essential amino acids 250 cc / 24h / intravenous
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Allopurinol 100 mg / 48h / oral
Cor: I / II regular heart sound, no murmur. Ca polystyrene sulfonate 5 gram / 8h / oral
Abdomen: Peristaltic normal impression, no ascites, Amlodipine 10mg / 24h / oral
Excremitas: warm akral, no udema, crepitation on genu sinistra, tofus HD initiation schedule confirmation
on MTP 1 and maleolus medial dextra
A: - Gout ndropathy dd obtruktif G5A3 Diagnostic plan:ADT, FE, TIBC.Ferritin
Hyperkalemia MSCT non contrast abdominal scan
Normocytic normocytic anemia Photos of genus sinistra
Hypertension on treatment Uric acid / 24 hours
Chronic gouty arthritis
Osteoarthritis genu sinistraBilateral hydronephrosis Plan Monitoring:Post HD electrolyte
Suspect urinary tract stone
BTKV S: weakness - Ceftriaxone 1gr/12h/intravena (2)
09.00 O: moderate pain, adequate nutrition, composmentis,
TTV: within normal limits, post dry DLC surgery
A: Post op day 1 DLC ec CKD

HD S: weakness exists, no fever, no shortness of breath. Terapi:

18-01-2018 O: general status : good Hemodialisa initiation
TD 141/75N: 90x / min, P: 20x / m, S: 36C TD : 2 hours
Eyes: an anemic conjunctiva exists, no jaundice sclera Qb : 150 ml/minutes
Neck: JVP R + 1 cmH20 Qd : 300 ml/minutes
Thorax: A vesicular breath sound, no Ronkhi, no wheezing UFG : 500 ml
Cor: I / II regular heart sound, no murmur. HCO3 : 14,3
Abdomen: Peristaltic normal impression, no ascites, Temp : 37,2
Excremity: warm, acral no udema, creoitation on genu sinistra, tofus DLC access
on MTP 1 and maleolus medial dextra
A: Gout nephropathy dd obstructive G5D initiation
BTKV S: weakness Therapy:
19-01-2018 O: Moderate, conscious, TTV: within normal limits, the DLC surgery wound appears dry - Ceftriaxone 1gr/12jam/intravena (3)
A: Post DLC day 2 ec of obstructive nephropathy
Interna S: Limp still exists, post HD initiation Plan Therapy:
19-01-2018 O: TD: 120/70, N: 84x / min, S: 36.7C, P = 20x / min Low protein diet 1.2 gr / KgBB / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine, potassium, phosphate diets
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Essential amino acids 250 cc / 24h / intravenous
Cor: I / II regular heart sound, no murmur. Allopurinol 100 mg / 24h / oral
Abdomen: Peristaltic normal impression, no ascites, Ca polystyrene sulfonate 5gr / 8jam / oral
Excremity: warm akral, no udema, krepitasi on genu sinistra, tofus on MTP 1 and maleolus Amlodipine 10mg / 24h / oral3x / week regular
medial dextra HD
Laboratory:Na: 130 Potassium 6.2 Cl 96 Ferritin 12000 Fe 70 TIBC 138 Erythropoetin 3000 IU / Subcutaneous, 2x / week
Saturation Transferrin: 50,72%ADT: normocytic normocytic anemia with a picture of decreased
renal function and chronic disease. Diagnostic Plan:MSCT non contrast abdominal scan
Photo genus sinistra AP / lateral (19/1/2018):Alignment genus sinistra intake, no dislocation, No Uric acid / 24 hours
visible fractures and bone destruction,Visible osteophytes on the condylus lateralis et medialis os
tibia sinistra, eminentia intercondylar lateralis os tibia sinistra,Femoropatella joint gaps and
femorotibia are good impression.The soft tissue around the impression is good.I mpression:OA
genus sinistra grade II
A: Gout ndropathy dd obtruktif G5D
Hyperkalemia -
Renal anemia
Hypertension on treatment
BTKV S: weakness Plan Therapy:
20-01-2018 O: Moderate, conscious, TTV within normal limits, wound Ceftriaxone 1gr/12h/intravena (4)
DLC operation looks dry
A: Post OP DLC day 3
Interna S: Limp still exists, vomiting after taking meals, no heartburn Therapy :
20-01-2018 O:TD: 160/90 mmhg N: 88x / mP: 20x / mS: 37 C Low protein diet 1.2 gr / KgBB / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine, potassium, phosphate diets
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Essential amino acids 250 cc / 24h /
Cor: I / II regular heart sound, no murmur. intravenous
Abdomen: Peristaltic normal impression, no ascites, Ondansetron 4 mg / 8h / intravena
Excremity: warm akral, no udema, krepitasi on genu sinistra, Allopurinol 100 mg / 24h / oral
tofus on MTP 1 and maleolus medial dextra Ca polystyrene sulfonate 5gr / 8h / oral
Abdominal MSCT: Right ureter hydrochloride et causa Amlodipine 10mg / 24h / oral3x / week
ureterolith regular HD
1/3 proximal ureter with nefrolith Erythropoetin 3000 IU / Subcutaneous, 2x
Left hydronefrosis with nefrolith / week
A: - Gout dd nepropathy dd obtruktif G5D
Interna S: Left knee pain Plan therapy
21-01-18 O:VAS 4/10 - Paracetamol
Jam 10.00 Genus Sinistra: udema exists, effusion 1000mg/8h/oral
exists, tenderness exists, ROM - Continue others therapy
decreases, crepitations exist.
Nat: 132
Kal: 4.9
Clor: 98
Wbc: 8460
Hb: 7
Plt: 274000
Neut 71%
MCV: 86.2
MCH: 28.5
LED I / II: 18/27

A - Osteoarthtritis genus sinistra with

effusion
BTKV S: weakness - Continuing therapy of TS GH
22-01-2018 O: moderate pain, adequate nutrition, composmentis Dry DLC - Loose from interna
surgery wound - Please consult again if DLC is not patent
A: post DLC day 5

Interna S: still weak, nausea sometimes, no vomiting, left knee pain Therapy :
22/01/2018 O: TD 130 / 90mmhg N: 90x / min P: 20x / min S: 37C VAS 3/10 Diet low protein 1.2 g / kg / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine diet, potassium phosphate
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Transfusion PRC I unit intra HD
Cor: I / II regular heart sound, no murmur. Essential amino acids 250 CC / 24h / intravenous
Abdomen: Peristaltic normal impression, no ascites, Allopurinol 100mg / 24h / oral
Excremity: warm, akral no udema, tofus on MTP 1 and medial Paracetamol 1 gr / 8jam / oral
dextra malleolus Genus sinistra look udem, no rubor and heat, Amlodipine 10 mg / 24 hours / oral
there is limited range of movement, crepitation and tenderness. Ondansetron 4 mg / 8jam / intravena if necessary
A - Osteoarthritis genus sinistra with effusion Regular hemodialysis 3x / week(Tuesday, Thursday,
- Obstructive nephropathy G5D Saturday)
- Renal anemia Erythropoetin 3000 IU / Subcutaneous, 2x / week
- Chronic Arthritis Goutwith tophus Plan:Consul Ts. Rheumatology
- Hypertension on treatment Uric acid / 24 hours
- Bilateral hydronephrosis
- Ureterolitiasis bilateral dextra et nephrolithiasis
22-01-2018 S: Pain and feeling stiff on the left leg 5 days ago felt slowly. Pain Therapy:
23/01/2018 S: weak, nausea sometimes, left knee pain Plan therapy:
Interna O: TD: 130/90 N: 88x / m R: 20x / minute S: 36.7C, VAS 3/10 Diet low protein 1.2 g / kg / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine diet, potassium phosphate
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Essential amino acids 250 cc / 24h / intravenous
Cor: I / II regular heart sound, no murmur. Paracetamol 1gr / 8jam / oral
Abdomen: Peristaltic normal impression, no ascites, Meloxicam 7.5 mg / 24h / oral
Excremity: warm, akral no udema, tofus on MTP 1 and medial malleolus Colchisin 0.5 mg / 24h / oral
dextra, Genus sinistra look udem, no rubor and heat, there is limited Amlodipine 10 mg / 24 hours / oral
range of movement, crepitation and tenderness. Ondansentron 4 mg / 8jam / intravena (if necessary)
A: - Osteoarthritis genus sinistra with effusion G5D obstructive Erythropoetin 3000 IU / Subcutaneous, 2x / week
nephropathy Regular hemodialysis 3x a week
Renal anemia Transcusi PRC 1 unit intra HD
Chronic Arthritis Gout with tophus
Hypertension on treatment Plan:Arthrosynthesis
Bilateral hydronephrosis Analysis of joint fluid
Ureterolitiasis bilateral dextra et nephrolithiasis Ur / Cr post HDDR post transfusion
Wait for uric acid results urine
Rheuma S: pain and edem on the left knee, hard to bend. Pain increases with touches. Paracetamol 1gr / 8h/ oral
23-01-2018 History of pain on both feet and toes Meloxicam 7.5 mg / 24h / oral
O: TD 130/80 n: 88x / min r: 20x / min s: 37 VAS 3/10 Colchicine 0.5 mg / 24 hours / oral
Eyes: anemis exists, no jaundice Allopurinol 100 mg / 24 hours / oral
Thorax: no ronkhi and wheezing Injection of intramarticular 10 mg of
Status of RheumatologyGait: unable to walk triamcinolone
Arms: normal
24/01/2018 S: limp exists, no nausea, left knee pain is reduced, fever does not exist, no Plan therapy:
Interna cough, no micturition pain, yellow stool Diet low protein 1.2 g / kg / day
O: TD: 130/90 n 80x / min p 20x / minute s 36.7 CVAS: 2/10 Low sodium diet <2gr / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low purine diet, potassium phosphate
Neck: JVP R + 1 cmH20 Paracetamol 1gr / 8jam / oral
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Meloxicam 7.5 mg / 24h / oral
Cor: I / II regular heart sound, no murmur. Essential amino acids 250 cc / 24h / intravenous
Abdomen: Peristaltic normal impression, no ascites, Allopurinol 100mg / 24h / oral
Excrimity: warm, no udema, tofus on MTP 1 and medial dextra Colchisin 0.5 mg / 24h / oral
malleolusGenus sinistra not udem, no rubor and heat, tenderness and Amlodipine 10 mg / 24 hours / oral
limited range of movement is reduced, krepitasi exist.Lab:WBC: 8560NEUT: Regular hemodialysis 3x / week
88.1%HGB: 8MCV: 85.8MCH: 28.4PLT: 339.103UR: 293CR: 26,33Uric acid: 110 Erythropoetin 3000 IU / subcutan 2x / week
A: - Gout dd nepropathy dd obtruktif G5D Plan:urine routine
Osteoarthritis genus sinistra with intra-articular injection post-injection wait result of joint fluid analysis
Renal anemia
Hypertension on treatment
Chronic gout arthritis bertofus
Bilateral hydronephrosis
Ureterolitiasis bilateral dextra et nephrolithiasis

24-01-2018 S: pain in the left knee Plan Therapy:

Rheuma O: Rheumatology status Low purine diet
Gait: unable to walk Paracetamol 1000mg / 8hours
Arms: normal Meloxicam 7.5 mg / 24 hours / oral
25/01/2018 S: Knee pain decreases,weakness begins to decrease, fever is absent, micturition pain Plan therapy:
Interna does not exist.O: TD 130/80, n 80x / min, S 36.5C, R: 20x / min, VAS: 2/10 Diet low protein 1.2 kg / BB / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine, potassium, phosphate diets
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Levofloxacin 500mg / 24h / intravenous
Cor: I / II regular heart sound, no murmur. (1)Essential amino acids 250cc / 24h / intravenous
Abdomen: Peristaltic normal impression, no ascites, Allopurinol 100 mg / 24 hours / oral
Excrimity: warm, no udema, tofus on MTP 1 and medial dextra malleolusGenus sinistra Colchisin 0.5 mg / 24h / oral
not udema, no rubor and heat, tenderness and limited range of movement is reduced, Amlodipine 10mg / 24h / oral
krepitasi exist.Spine: normal Meloxicam 7.5mg / 24h / oral
Lab: (25-01-2018)Urine routine:Prot: 3+Glu: 1+Sed Erit: 7Sed Leu: 28Bacteria: 11 Paracetamol 1gr / 8jam / oral3x / week
A: - Complicated UTIs, regular HD
Gout nephropathy in G5D obstruction Erythropoetin 3000 IU / Subcutaneous, 2x / week
OA of the left genus accompanied by post-injection intra-articular effusion Plan:Urine culture and antibiotic sensitivity
Renal anemia Ureum, creatinine and post HD electrolytes
Hypertension on treatment Wait for the result of joint fluid analysis
Chronic gout arthritis bertofus
Bilateral hydronephrosis
Ureterolitiasis bilateral dextra et nephrolithiasis

HD S: limp exists, no fever, no shortness of breath. Therapy:

25-01-2018 O: KU: RightTD 130/75 mmhg, N: 90x / min, P: 20x / m, S: 36, 4C Regular hemodialysis
Eyes: an anemic conjunctiva exists, no jaundice sclera TD: 4 hoursQb: 180 ml / minQd: 400 ml / minUFG: 1000
Neck: JVP R + 1 cmH20 mlHCO3: 14.6 Temp: 37
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Access DLC
Cor: I / II regular heart sound, no murmur.
Abdomen: Peristaltic normal impression, no ascites,
26/01/2018 S: Knee pain decreases, weaness begins to diminish, nausea absent, fever is absent, micturition pain - Low protein diet <1.2 kg / BB / day
interna is absent. - Low sodium diet <2gr / day
O: TD 130/80, n 80x / min, S 36.5C, R: 20x / min, VAS: 2/10 - Low purine, potassium, phosphate diets
Eyes: an anemic conjunctiva exists, no jaundice sclera - Levofloxacin 500mg / 24h / intravenous
Neck: JVP R + 1 cmH20 - (2)Essential amino acids 250cc / 24h / intravenous
Thorax: A vesicular breath sound, no Ronkhi, no wheezing - Allopurinol 100 mg / 24 hours / oral
Cor: I / II regular heart sound, no murmur. - Colchisin 0.5 mg / 24h / oral
Abdomen: Peristaltic normal impression, no ascites, - Meloxicam 7.5mg / 24h / oral
Excremity: warm akral, no udema, tofus on MTP 1 and medial dextra malleolus Genus sinistra not - Paracetamol 1gr / 8jam / oral (k / p)
udema, no rubor and heat, tenderness and limited range of movement is reduced, krepitasi - Amlodipine 10mg / 24h / oral3x / week
exist.Spine: normalLab: 25/1/2018Ur: 167Cr: 12.6Nat: 133Kal: 4.5Clor: 92 - regular HD
A - Complicated UTIs - Eriropoetin 3000 IU / subcutan 2x / week
Gout nephropathy in G5D obstruction - Plan:Wait for urine culture results
OA of the left genus accompanied by post-injection intra-articular effusion - Wait for the result of joint fluid analysis
Renal anemia
Hypertension on treatment
Chronic gout arthritis with tophus
Bilateral hydronephrosis
Ureterolitiasis bilateral dextra et nephrolithiasis
26-01-2018 S: left knee pain is reduced Plan therapy:
Rheuma O: Eyes: Anemis exists. no jaundice sclera Low purine diet
Gait: unable to walkArms: normal PCT 1000 mg / 8 hours / oral
Legs: Genu sinistra not udema, no rubor and calor, tenderness limited range of movement is Meloxicam 7.5 / 24 hours / oral
reduced, crepitation exist. Colcisin 0.5 mg / 24 hours / oral
Spine: normal Allopurinol 100mg / 24h / oral
Lab: 25/1/2018Uric acid: 12Uric acid: 110 joint fluid analysis (Wait for results)
27-01-2018 S: Fever is absent, micturition pain is absent, urin is yellow, knee pain decreases Plan therapy:
interna O: TD 130/80, n: 80x / min, R: 20x / min, s: 36.6C, VAS: 2/10 Low protein diet <1.2 kg / BB / day
Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine, potassium, phosphate dietsLevofloxacin
Thorax: A vesicular breath sound, no Ronkhi, no wheezing 500mg / 24h / intravenous (3)
Cor: I / II regular heart sound, no murmur. Essential amino acids 250cc / 24h / intravenous
Abdomen: Peristaltic normal impression, no ascites, Allopurinol 100 mg / 24 hours / oral
Excremity: warm akral, no udema, tofus on MTP 1 and medial dextra malleolus Genus sinistra no Colchisin 0.5 mg / 24h / oral
udema, no rubor, calor and tenderness, limited range of movement is reduced, krepitasi exist. Meloxicam 7.5mg / 24h / oral
Spine: normal Paracetamol 1gr / 8jam / oral (if necessary)
Result of analysis Fluid joints: Volume: 11Calculate cell type: PMN = 91% MN = 9%Total Amlodipine 10mg / 24h / oral3x / week
protein: 4200.0 LDH: 505Glucose test: 95Count cell: 3525Musin test: Poor Vischosithas: regular HD
<2cmFreeze: negative PH: 8.0 YellowBJ: 1,010A Eriropoetin 3000 IU / subcutan 2x / week
- Complicated UTIs
Gout nephropathy in G5D obstruction
OA of the left genus accompanied by post-injection intra-articular effusion
Renal anemiaHypertension on treatment
Chronic gout arthritis with tophus
Bilateral hydronephrosis
Ureterolitiasis bilateral dextra et nephrolithiasis
27-01-2018 S: knee pain exists Plan therapy:
Rheuma O: Eyes: Anemis exists. no jaundice sclera Low purine diet
Gait: unable to walk Paracetamol 1000 mg / 8 hour / oral
Arms: normal Meloxicam 7.5 / 24 hours / oral
Legs: Genu sinistra not udema, no rubor, calor and tenderness, limited range of movement is reduced Colcisin 0.5 mg / 24 hours / oral
and krepitasi exist. Allopurinol 100mg / 24h / oral
28-01-2018 S: Fever Plan Therapy
Interna O: TD: 130/80, n: 102x / min, S: 38.7c r: 20x / min - Levofloxacin 500mg/24h/oral (4)
16.00 Eyes: an anemic conjunctiva exists, no jaundice sclera - Paracetamol 1gr/8h/intravena
Neck: JVP R + 1 cmH20
Thorax: A vesicular breath sound, no Ronkhi, no wheezing
Cor: I / II regular heart sound, no murmur.
Abdomen: Peristaltic normal impression, no ascites,

A: - complicated UTI
29-01-2018 S: Fever exists, nausea exists, vomiting exists Plan Therapy:
Interna O: TD: 130/80, N: 105x / min, S: 37.8C R: 20x / min Low protein diet <1.2 kg / BB / day
06.00 Eyes: an anemic conjunctiva exists, no jaundice sclera Low sodium diet <2gr / day
Neck: JVP R + 1 cmH20 Low purine, potassium, phosphate diets
Thorax: A vesicular breath sound, no Ronkhi, no wheezing Meropenem 1gr / 8jam / intravena (1)
Cor: I / II regular heart sound, no murmur.Abdomen: Peristaltic normal impression, Levofloxacin 500mg / 24h / intravenous (5)
no ascites, Essential amino acids 250cc / 24h / intravenous
Excremity: warm akral, no udema, tofus on MTP 1 and medial dextra malleolus Allopurinol 100 mg / 24 hours / oral
Genus sinistra not udema, no calorie rubbers and tenderness, limited range of Colchisin 0.5 mg / 24h / oral
movement is reduced, krepitasi exist. Meloxicam 7.5mg / 24h / oral
Spine: normal Paracetamol 1gr / 8jam / intravena
qSOFA SCORES: 0 Ondansentron 4mg / 8jam / intravena
A: - ISK komplikata s Amlodipine 10mg / 24h / oral3x / week
uspicious Urosepsis regular HD
Gout nephropathy in G5D obstruction Eriropoetin 3000 IU / subcutan 2x / week
OA of the left genus accompanied by post-injection intra-articular effusion
Renal anemia Plan:Control of urea, creatinine, DR, procalcitonin and urinalysis.
Hypertension on treatment Wait for urine culture results
Chronic gouty arthritis Keep an eye on vital signs
Bilateral hydronephrosis
Ureterolitiasis bilateral dextra et nephrolithiasis
29-01-2018 S: Shortness is present, Cough with white phlegm, fever present Plan therapy:
17.00 O: TD: 110/80 mmhg, N: 110x / min, P: 28 x / min, S 38 C, SpO2 96% O2 4 liters / minute
Eyes: an anemic conjunctiva exists, no jaundice sclera N-acetylsistein 200 mg / 8h / oral
Neck: JVP R + 1 cmH20
Thorax: Bronchovesikuler breath sound, Ronkhi medio basal dextra and basal sinistra, no wheezing Diagnostic Plan: Photo thorax control, Sputum culture and antibiotic
30-01-2018 S: Patients complain the short of breth is getting severe, white cough with - Put O2 NRM 10 liters / min
05.30 phlegm, fever present - Install the monitor
O: TD: 100/70 N: 125x / min S: 38.9 C R: 36x / min, O2 saturation 81% - Install Catheter urine, fluid balanced
Eyes: an anemic conjunctiva exists, no jaundice sclera - Treat ICU
Neck: JVP R + 1 cmH20 - AGD
Thorax: Bronkovesikuler breath sound, Ronkhi difuse bilateral, wheezing no. - CXR Control
Cor: I / II regular heart sound, no murmur. - EKG
Abdomen: Peristaltic normal impression, no ascites, - Consule to Ts. Pulmonology
Laboratory results (29-01- 2018) Ureum: 132Creatinin 9.90 Procalcitonin> 200.0 - Consul Ts. Tropical infections
Urine routine:Prot: 3+Sed erit: 30Sed leu: 192Bacteria 24
A: - ARDS
Urosepsis
30-01-2018 S: The patient suddenly stops breathing - RJP 7 cycle
Interna O: The pulse is not palpable, TD is not measurable,
06.05
Interna Patients do not respond, pupils of total midriasis - The patient is declared dead.
06.20
Conceptual Structure

Hiperurisemia Nefropati gout

Hiperkalemia

Artritis Gout Nefropati

BSK ESRD Anemia
kronik bertofus obstruksi

OA Hipertensi
ISK
Komplikata

Urosepsis

ARDS
 a 53-year-old male patient was admitted to hospital with complaints of weakness
experienced since 2 weeks ago, intake less than 1 week, nausea, previously
hospitalized at Kendari Hospital for 1 week and diagnosed with failure of kidney,
patient has administered 4 pc PRC transfusion and received telmisartan medicine
80 mg once in a day. Then, was then referred to RS Wahidin Sudirohusodo with a
hemodialysis plan.
 The sandy urination is present, the history of hypertension since last 2 years, the
history of gout has been felt since the last 10 years, from physical examination,
blood pressure 150/90 mmhg, anemic conjunctiva, in extremity there is crepitation
on genus sinistra, tofus at MTP 1 and medial malleolus dextra, from laboratory
results showed a significant value of Hb 8.5, MCV 90, MCH 29, Potassium 6, Ureum
352, Creatinin 26.74 (GFR 2ml / mnt / 1,7m2), uric acid 16, urinalisa: prot +++ / 300,
Abdominal Ultrasound Result: Bilateral Hydronefrosis, abdominal MSCT results
without contrast: Right ureteral hyper et causa ureterolith 1/3 proximal ureter with
nephrolith and left hydronephrosis with nefrolith. So patients assesed with gout
nephropathy in obstruction G5A3 + Hyperkalemia + normochrom normocytic
anemia + Hypertension grade 1 + Chronic gouty arthritis + OA genus sinistra +
Bilateral hydronefrosis + bilateral nilrolith et ureterolitiasis dextra. In the 5th day
care of patients in the consul to rheumatology colleagues with OA genus sinistra
accompanied by effusion + chronic gout arthritis, on day 8 treatment out the
urinalysis results 28 leukocyte sediment and urine bacteria 11 , so that assesed as
complicated UTI (urinary tract infection) .
 In the 12th day treatment of patients starting febris suspected as a result of
urosepsis, the next day on the 29th of the patient there was a shortness of the
breath, complaint accompanied by a cough, and on the 30th at 5:30 am getting
severe and heavily burdened, shortly afterwards the patient is getting upneu,
doctor was performed RJP 7 cycle but the patient did not respond, the pulse was
not palpable, the tension was not measurable, the pupils were total midriasis and
the patient was declared dead in front of the family at 06.15 Wita.
Discussion
 The 53-year-old male patient came with nausea, anorexia complaints since 2 weeks
before hospital admission to . A sandy urination history was exists. The patient is a
referral patient from Kendari Hospital with CKD stage 5 hemodialysis plan. Gout
history is present> 10 years and patients taking allopurinol drug 1x 100 mg daily.
In the physical examination of the extremities found tofus in MTP 1 and maleolus
medial pedis dextra, the laboratory obtained ureum 352, creatinin 26,74 (eGFR 2ml
/ mnt / 1.73 m2), uric acid 16, urine protein +++ / 300 , on abdominal ultrasound
examination there is bilateral hydronefrosis and in non-contrast abdominal MSCT
there is presence of right hydronephroureter et causa ureterolith 1/3 proximal
ureter with nephrolith, left hydronephrosis accompanied by nephrolith, so that the
patients assesed with gout nephropathy in obstruction of G5A3.
 This patient is a patient with renal failure with eGFR <15 ml / min , so it is
recommended to get renal replacement therapy in the form of hemodialysis. Gout
nephropathy is a state of uric acid or ureterary crystal deposited on the
parenchyma and tubular lumen independently and causes direct injury to the
kidneys over a period of time, resulting in a renal failure. Gout nephropathy is a
form of chronic renal disease induced by accumulation of monosodium in the
medullary interstitial, which causes chronic inflammatory respon, similar to that in
the formation of tofus microstructure in other parts of the body, potentially leading
to interstitial fibrosis and chronic renal failure.1,13
 In this patient obtained the results of laboratory potassium 6 so that assesed as
hyperkalemia, in patients ECG not obtained T-Tall. Hyperkalemia is classified into
three levels: mild (5-6 meq / L), moderate (6.1-7.0 meq / L) and severe (> 7 meq / L
with ECG change). In these patients classified as mild hyperkalemia, hyperkalemia
therapy in these patients is given 5 grams / 8h / oral cation exchange (sodium
polysterene sulfonate) in which the drug contains Ca2 + ions in a group of
sulfonate resin radicals that are styrene divinyl benzene compounds. By working
mechanism as ion exchange resin. Calcium polisterene sulfonate releases Ca2 +
ions and binds K + ions through adsorption
 On oral administration this drug results in the process of ion exchange in the
gastrointestinal tract, expressed in the feces and does not effect spontaneous motor
activity. Kidney is the main regulator potassium balance by regulating the amounts
expressed in the urine, whereas in patients with chronic renal failure there is a
decrease in glomerular filtration rate so that the kidneys can not perform their
function. According to mild hyperkalemia therapy guidelines are diuretics:
furosemide 40-80 mg / intravena, resins: Kayexalate 15 - 30 gr in 50-100 ml 20%
sorbitol peroral or per rectum11.
 The laboratory results showed Hb 8.5, MCV 90, and MCH 29 resulting assesed as
normocytic normocytic anemia. The cause of normochromic normocytic anemia in
this patient has been evaluated iron status with 50.72% transferrin saturation so
that the cause of anemia in this patient is due to impaired renal function (renal
anemia). Renal anemia results from a lack of erythropoietin production caused by
chronic kidney disease5. Other things that can play a role in the occurrence of
anemia in patients with chronic renal failure are FE deficiency, blood loss,
shortened erythrocyte life, folic acid deficiency, and acute and chronic
inflammatory processes6 , 12.
 Patients is known has a history of hypertension over the last 2 years with blood
pressure while entering hospital is 150/90 mmhg, the blood pressure classification
based on JNC 7 was classified as stage 1 hypertension, resulting in asses as stage 1
hypertension. In patients given antihypertensive amlodipine 10 mg / 24h / oral
with blood pressure decrease target <150/90 mmhg.4 Patients have a history of
gout since> 10 years, on physical examination found tofus on MTP 1 and malleolus
medial pedis dextra. Upon admission to the hospital, admission to hospital is no
sign of acute exacerbation resulting in asses of chronic gouty arthritis and given
Allopurinol 100 mg / 24h / oral therapy. Where allopurinol and its active
metabolites, oxypurinol, inhibit the enzyme xanthine oxidase, block the conversion
of hypoxanthine oxypurines and xanthones to uric acid
 Abdominal ultrasound examination results showed bilateral hydronefrosis and non-
contrast abdominal MSCT in the presence of right hydronephroureter et causa
ureterolith 1/3 proximal ureter with nephrolith, left hydronephrosis with nephrolith.
So in assesed as bilateral hydronefrosis due to urinary tract stones, the patient
consuled to urology colleague. Complications of gout arthritis include severe
degenerative arthritis, secondary infection, kidney stones and joint fractures. Gout
arthritis has long been associated with an increased risk of kidney stones. Patients
with gout arthritis build kidney stones because urine has a low pH that supports the
occurrence of insoluble uric acid.5,6
 In the 5th day of treatment the patient complained of left-hand tenderness with a
visible udema, no rubor and heat, there is limited range of movement, tenderness,
effusion and crepitation, the results of genu dextra xray photo showed
osteoarthritis genu sinistra grade II, arthrosynthesis and obtained results analysis
of joint fluid PMN = 91% MN = 9%, Total protein 4200, LDH 505, 95 glucose test, cell
count 3525, viscosity <2cm, PH 8.0, yellow, and BJ 1.010 and PA results show
inflammatory lesions ( suitable for osteoarthritis). So in assesed as OA genu sinistra
accompanied by effusion. Osteoarthritis in these patients may be primary or
idiopathic OA or may also a secondary of chronic gouty arthritis. Osteoarthritis in
patients according to American College Rheumatology (ACR) criteria, which is
knee joint pain and fulfills 3 of 6 criteria, ie crepitus during active motion, stiff joint
<30 min, age> 50 years.7
 The accumulation of monosodium uric crystal will interact with phagocytes through
two mechanisms, the first mechanism is by activating the cells through the
conventional route of opsonization and phagocytosis and secreting inflammatory
mediators. The second mechanism is the crystalline monosodium uric interacting
directly with the lipid membrane and proteins through the cell membrane and
glycoprotein in the phagocytes. In addition neutrophils contribute to the
inflammatory process through chemotactic factors ie cytokines and chemokines
that play a role in endothelial adhesion and transmigration processes. A number of
factors known to play a role in the process of gouty arthritis are IL-α, IL-8, CXCL1,
and granulocytestimulating-colony factor. Inflammation is an important factor in
gout arthritis. This reaction is a non-specific body defense reaction to avoid tissue
damage caused by the causative agent.
 The purpose of the inflammatory process is to neutralize and destroy the causative
agent and prevent the expansion of a wider causative agent, an inflammatory
reaction that plays a role in the process involving macrophages, neutrophils, which
in turn produce various chemical mediators such as TNF-α, interleukin-1,
interleukin-6, interleukin-8, alarmin and leukotrien. Patients performed
arthrosynthesis for evacuation of genuine effusion and intraarticular steroid
injection to reduce inflammation. According to his VAS, the pain experienced by
patients is moderate pain. Patients were then given combination therapy of
paracetamol and NSAIDs.8
 Result of urinalysis obtained 28 leucocyte sediment, bacteria 11, sediment of
erythrocytes 7, so that this patient and assesed with complicated urinary tract
infection. Based on the 2016 clinical practice manual said that the Urinary tract
infection is divided into a simple / non-compliant UTI is a UTI that occurs no
structural or kidney dysfunction and Complicated UTI located other than in vesika
urinaria, UTI in children, men or mothers pregnant9.
 According to guidelines for complicated UTI management begins with empirical
antibiotics, prolonged empirical therapy may lead to antimicrobial resistance.
Empirical therapy should be replaced in accordance with urine culture, therefore
urine culture should be performed before antimicrobial therapy begins. Dose
adjustment is required in patients with renal failure. Some options for empirical
antibiotics for complicated UTIs, namely third-generation cephalosporins such as
Ceftriaxone as first-line. Alternative aminoglycosides, Trimethoprim-
Sulfamethoxazole. Antibiotic recommendations when initial therapy fails or severe
cases of fluoroquinolone (if not used early in therapy), piperacillin + Beta lactam
inhibitor and carbapenem. In the course of the patient then complained of fever
with prokititin> 200 so that suspected urosepsis, patients then given additional
antibiotics karbapenem class while waiting for the results of urine culture9
 In the 13th day of treatment the patient complained of progressive cough and
dyspnea, the physical examination found rheumatic diffuse and there was a
decrease in oxygen saturation so that the patient was suspected to be ARDS. Acute
Respiratory Distress syndrome is a condition when the lungs are heavily scattered,
affecting the ability to take oxygen. The low levels of oxygen in the blood and the
inability to take oxygen at normal levels are a typical symptom of ARDS. ARDS is
diagnosed when it manifests as a respiratory failure in the form of acute hypoxemia
not due to increased pulmonary capillary pressure. The pathogenesis of ARDS
begins in the destruction of the alveolar epithelium and the microvascular
endothelium. Initial damage can result from direct or indirect injury. One of the risk
factors associated with systemic ARDS is sepsis, among others. Management of
ARDS is essentially addressing severe hypoxemia, treating the underlying cause of
ARDS and supportive measures to prevent complications10.
 Then, patients become apneu because of respiratory failure, performed heart
resuscitation but did not respond.
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