A 55 years old Man Came In With Severe Shortness of Breath Since 1 Day

Before Admission
Luthfy Uly M. Sihite*, Nelvin*, Eddy M. Salim**
ABSTRACT
still young, 1 bottle every 2-3 days. Family history
was free from hypertension, diabetic, kidney
disease and heart disease. Based on physical
examination, high blood pressure 150/100mmHg,
patient swelling at his eyelid, conjunctiva palpebral
was pale, ronkhi present, convex abdomen, shifting
dullness (+), scrotum edema (+), pretibia edema
(+). From the laboratory findings Hb: 8 mg/dl,
erythrocyte: 3.01x106, leucocyte: 12.000/mm3,
hematocrite: 24%, MCV: 79.4fL, MCH: 27pg,
LED: 108mm/hour, pH: 7.302, pCO2: 24.4, HCO3:
12.2, ureum: 237mg/dL, creatinine: 14.14mg/dL,
BSPP: 286. Urinalysis showed protein +++,
glucose ++,keton +, blood ++, cylinder +, bactery +
+. Hence, patient was diagnosed with Chronic
Kidney Disease stage V + DM type II +
Hypertension stage II.

It was reported a case with shortness of

breath and Chronic Kidney Disease at RSMH. A 55
years old man was admitted with a chief complain
of shortness of breath since 1 day before admission.
Dua tahun yang lalu, pasien mengeluh sering haus,
sering lapar, BAK menjadi lebih sering, dan sering
terbangun di malam hari karena BAK. Kemudian
os memeriksakan gula darah dan tekanan darah.
Dikatakan tinggi dan diberi obat penurun gula
darah dan tekanan darah. One month prior to
admission, patient complained about swelling on
foot in the morning after awakening. Shortness of
breath that relieve with rest and oxygen. Decreased
in urinationthan usually, 3-4 x/day. Two weeks
prior to admission, patient complained about
swelling spreadto thigh. The patient was difficult to
walk. Shortness of breath more severe but still
relieve with rest and oxygen. Nausea (+).
Decreased of appetite (+). Frequency of urination
still like before. One week prior to admission,
patient complained that he was often shortness of
breath but still relieve with rest and oxygen,
nausea, and decreased of appetite. But, his stomach
was getting bigger and tight. Patient just stay in bed
because he was difficult to walk. Frequency of
urination less than before, 2-3 x/day. One day prior
to admission, patient complained of severe
shortness of breath, not relieve with rest and
oxygen. Swelling of whole body. Frequency of
urination was 1 x/day. Patientcame toEmergency
Instalation of Mohammad Hoesin Hospital and was
hospitalized. Patient has medical history of
hospitalized in Charitas hospital 4 month ago
because shortness of breath, doctor said that he has
enlarged heart. Hypertension since 2 years ago,
there was medication with amlodipine but he was
not routine consume the medication and controlled
to doctor. Diabetes Mellitus since 2 years ago, there
was medication with glibenclamide and glimepiride
but he was not routine consume the medication and
controlled to doctor medication. Patient was also a
smoker, since 15 years ago with daily of 2-3 box.
History of drinking a cup of coffee everymorning
until now. History of drinking alcohol when hes

Keywords : Chronic Kidney Disease, Diabetes

Mellitustype II, Hypertension stage II

* Medical Student of Sriwijaya University, Clerkship Program

Moh.Hoesin General Hospitalq
** Staff of Allergy-Immunology Division of Internal Medicine
Department of Dr. Moh. Hoesin General Hospital

INTRODUCTION

CASE ILLUSTRATION
A 55 years old man who lives at
RatuSianumstreet, Ilir Barat II, Palembang, was
admitted in Moh.Hoesin General Hospital on 16th
June 2016 with chief complaint of shortness of
breath since 1 day before admission. Dua tahun
yang lalu, pasien mengeluh sering haus, sering
lapar, BAK menjadi lebih sering, dan sering
terbangun di malam hari karena BAK. Kemudian
os memeriksakan gula darah dan tekanan darah.
Dikatakan tinggi dan diberi obat penurun gula
darah dan tekanan darah. One month prior to
admission, patient complained about swelling on
foot in the morning after awakening. Shortness of
breath that relieve with rest and oxygen, wheezing
(-), influenced by weather (-), influenced by

regular and body temperature 36.5oC. Physical

examination of the head, mouth, ears, throat,
showed no abnormalities, eyes physical
examination showed swelling at his eyelidand pale
conjungtiva palpebra. Physical examination of the
neck showed there are no enlargement of lymph
nodes and jugular venous pressure (5-2)cm H 2O.
The chest was symmetric, tactile fremitus was
symmetric upon both lungs,versicular sound was
normal,rales present upon both of lungs. For heart
examination, ictus cordis was not visible and
palpable, upon percussion it appeared slide
enlargement of the left heart boundary shifting
towards the left axial line on 5th ICS. On
auscultation, heart sound AI-AII, PI-PII, MI-MII,
TI-TII normal, no murmur and no gallop heard.
Inspection on the abdominal region showed no
abnormalities. In abdominal percussion there was
positive shifting dullness. On the palpation liver
and lien showed no abnormalities and normal
bowel sound was detected during auscultation. On
the upper extremities showed swelling and lower
extremities showed pretibial edema.

emotional (-), influenced by activity (-). Wake up in

the night because shortness of breath (-). Patient
can sleep with one pillow. Cough (-), sniffles (-).
Chest pain (-). Decreased in urination than usually,
3-4 x/day, bubbles in urine (-), red urine (-), cloudy
urine (-), fever (-). Two weeks prior to admission,
patient complained about swelling spread to thigh.
The patient was difficult to walk. Shortness of
breath more severe but still relieve with rest and
oxygen. wheezing (-), influenced by weather (-),
influenced by emotional (-), influenced by activity
(-). Wake up in the night because shortness of
breath (-). Patient can sleep with one pillow.
Nausea (+). Decreased of appetite (+). Frequency
of urination still like before. One week prior to
admission, patient complained that he was often
shortness of breath but still relieve with rest and
oxygen, nausea, and decreased of appetite. But, his
stomach was getting bigger and tight. Patient just
stay in bed because he was difficult to walk.
Frequency of urination less than before, 2-3 x/day.
One day prior to admission, patient complained of
severe shortness of breath, not relieve with rest and
oxygen, wheezing (-), influenced by weather (-),
influenced by emotional (-), influenced by activity
(-). Wake up in the night because shortness of
breath (-). Night sweating (-). Swelling over whole
body (+). Frequency of urination was 1 x/day.
Patient came to Emergency Instalation of
Mohammad Hoesin Hospital and was hospitalized.

From the laboratory findings Hb: 8 mg/dl,

erythrocyte: 3.01x106, leucocyte: 12.000/mm3,
hematocrite: 24%, MCV: 79.4fL, MCH: 27pg,
LED: 108mm/hour, pH: 7.302, pCO2: 24.4, HCO3:
12.2, ureum: 237mg/dL, creatinine: 14.14mg/dL,
BSPP: 286. Urinalysis showed protein +++,
glucose ++,keton +, blood ++, cylinder +, bactery +
+.

Patient has medical history of hospitalized

in Charitas hospital 4 month ago because shortness
of breath, doctor said that he has enlarged heart.
Hypertension since 2 years ago, there was
medication with amlodipine but he was not routine
consume the medication and controlled to doctor.
Diabetes Mellitus since 2 years ago, there was
medication with glibenclamide and glimepiride but
he was not routine consume the medication and
controlled to doctor medication. Patient was also a
smoker for approximately 25 years with daily of 23 box. History of drinking a cup of coffee
everymorning until now. History of drinking
alcohol when hes still young, 1 bottle every 2-3
days. Family history was free from hypertension,
diabetic, kidney disease and heart disease.

From chest x-ray it showed an enlarged

heart. Differential diagnosis of this patient could be
respiratory failure e.ccongestive heart failure with
renal failure e.c chronic kidney disease.
The patient and the family were informed
about from the aspect of non- pharmacology patient
was given diet protein 50 gram, fluid consumption
was controlled by maintenance, bed rest.
Pharmacology includes furosemide 2x20
mg IV, amlodipine 1x5 mg tablet per oral,
ceftriaxone 2x1 gram IV, folic acid 3x1 mg tablet
per oral, CaCO3 3x500 mg tablet per oral, and
routine haemodialysis. The patient showed a bad
functional prognosis but a good vital outcome.

Based on the condition of the patient he

was fully conscious, general appearance was
moderately sick with body weight 88 kg and height
170 cm, blood pressure 150/100 mmHg, pulse rate
94x/minute regular, respiration rate 30x/minute

Further examinations, such as laboratory

finding of globulin and albumin, Hb after
transfusion are needed to accurately sum up the
prognosis of the disease including the therapy.

From the laboratory findings Hb: 8 mg/dl,

erythrocyte: 3.01x106, leucocyte: 12.000/mm3,
hematocrite: 24%, MCV: 79.4fL, MCH: 27pg,
LED: 108mm/hour, pH: 7.302, pCO2: 24.4, HCO3:
12.2, ureum: 237mg/dL, creatinine: 14.14mg/dL,
BSPP: 286. Physical examination, high blood
pressure 150/100mmHg, patient swelling at his
eyelid, conjunctiva palpebral was pale, ronkhi
present, convex abdomen, shifting dullness (+),
scrotum edema (+), pretibia edema (+). Patients
laboratory results showed positive chronic kidney
disease. The management of patient with chronic
kidney disease and chronic disease anemia consists
of non pharmacology and pharmacology. Non
pharmacology is to explain about patients illness
to the family also including the therapy and
outcome, bed rest is required, diet protein. In
addition, fluid balance must be monitored strictly.
Pharmacology therapy for this patient
include furosemid 2x20 mg IV, amlodipine 1x5 mg
tablet per oral, ceftriaxone 2x1 gram IV, folic acid
3x1 mg tablet per oral, CaCO3 3x500 mg tablet per
oral, and routine haemodialysis. Diuretic in this
matter is used to reduce bilateral edema.

DISCUSSION
Chronic Kidney Disease is known as a
decreased glomerular filtration rate (GFR) of less
than 60 mL/min/1.73 m2 for 3 or more months.
Despite of the underlying etiology,the loss of
nephrons and reduction of functional renal mass
reaches a certain point where the remaining
nephrons begin a process of irreversible sclerosis
that leads to a progressive decline in the GFR.1The
patients GFR can be estimated with cockcroft
gault equation: GFR= [(140-Age) x bodyweight] /
[72 x plasma creatinin], and from the the equation
the GFR is 7.34mL/min/1.73 m 2 which can be
classified as stage 5 CKD.3
The most common caused of CKD in
Indonesia is glomerulonephritis.3 Glomerulonephritis is condition that consists of
hypertension,
hematuria,
mild
proteinuria,
degradation of kidney function, and edema. The
physical examination showed that the patient has
hypertension and edema. The urinalysis showed
mild proteinuri and hematuri, and the laboratory
findings showed elevated plasma creatinine which
can be the indication of degradation of the kidney
function. So, it is possible to conclude that the
cause of CKD in this patient is glomerulonephritis.3
Besides that, diabetes is the number one
cause of kidney failure in United States.4 Diabetes
can harm the kidneys by causing damage to blood
vessel inside our kidneys, nerves in our body, and
urinary tract. The filtering units of the kidney are
filled with tiny blood vessels. Over time, high sugar
levels in the blood can cause these vessels to
become narrow and clogged. Diabetic nephropathy
consist of 5 different stages depending on
glomerular damage. On this patient, there is a
possibility of renal failure because of the low GFR
(<15 mL/min per 1.73 m2), and sign of uremic
syndrome.
Hypertension also the one of the leading
causes of CKD due to the deleterious effects that
increased BP has on kidney vasculature. Longterm, uncontrolled, high BP leads to high
intraglomerular pressure, impairing glomerular
filtration.5 Evaluasi untuk menentukan adanya
kerusakan organ target, dalam hal ini ginjal, dapat
dinilai dengan adanya proteinuria/albuminuria serta
perkiraan GFR. Pada pasien ini sudah terdapat
proteinuria dan penurunan GFR. Jadi dapat
dipikirkan juga bahwa penyebab CKD pada pasien
ini adalah hipertensi.

CONCLUSION
We have discussed a case of chronic
kidney disease in a 55 year old, male patient who
also had shortness as breath, swelling over whole
the body, pulmonal edema including rales.
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