CBD

CHRONIC KIDNEY DISEASE

Patient identity
Name Sex Age Education Occupation Marital status Religion Nationality Address Admission date : RAS : female : 36 yo : elementary school : merchant : Married : Hindu : Indonesia : Br. Segara Kuta Badung : 24 November 2013

Anamnesis
Chief complain: Shortness of breath Present history:
Patient comes to ER RSUP Sanglah (24/11/2013) with chief complaint shortness of breath that was felt approximately 3 days BATH. This shortness of breath was felt in all part of the chest. It was felt like pressed by heavy burden. It was happens suddenly and persist all over the days and disturb patient activities, didnt get better with position changes and get worse when she cough

 Patient also complaint cough since 7 days BATH. The cough with release of sputum, yellow in color, without blood. The cough was happen suddenly and persist all over the days. The cough was said to be getting worse so it disturbs patient activities. The cough was improved with rest.

Anamnesis
Another complaint of the patient is fever since 3 days BATH. The fever was felt all over the body but didnt untill make patient shaking, and happen all days, getting better with antipyretic but after that relapse again. Beside that patient also complain of feeling weak since more than 1 week BATH . This was felt in all body, and persist all days. This complain was said to be like having no energy, didnt improve with meal or rest. Patient still can do daily activities but only for short time.

Anamnesis
Patient also complain of swelling since 3 day BATH in all of the body. It start appears in the face than the body untill the legs, and persist all the day, didnt improve with rest. Volume of urination was said to be reduced since 4 monts BATH, with 50-100cc in every urination. The urin was said to be clear and yellow in color. Defecation was said to be normal. Complain of nausea, vomitting, bloody vomitting, decrease of weight, nigt sweating, reduce of consciousness was denied. History of foamy and bloody urin was denied

Anamnesis
Past history Patient had hypertension since 5 years ago. Patient didnt control the hypertension routinely and didnt take medicine routinely. The blood pressure usually around 140/90 mmHg. Histrory of heart disease, diabetes mellitus, asthma, kidney disease, urinary tract stone, and gout was denied. Medication history Two weeks BATH patient was hospitalized in Kasih Ibu Hospital for 4 days. The complaint was said to be not improving. Patient was given some medicines but she didnt remember the names and usage of the drugs.

Anamnesis Family history None of the family member was said to had same complaint as the patient. History of kidney disease, hypertension, heart disese, diabetes mellitus, and asthma was denied Social history Patient used to work as merchant, because of her disease she didnt work again. Patient routinely consumes 2 cup of coffees since 8 years ago. History of smoking and alcohol was denied.

Physical examination
Appearance Consciousness Nutrition Blood pressure Pulse rate Respiration rate Axillary temp VAS Body height Body weight BMI : mildly ill : Compos mentis / E4V5M6 : good : 140/90 mmHg : 84 x/menit : 22 x/menit : 36,8 C : 0/10 : 150 cm : 50 kg : 22,2 kg/m2

Physical examination
Eyes : anemia -/-, icterus -/-, RP +/+ isochoric, palpebral oedema -/-

ENT
Neck

: tonsil T1/T1; pharing hiperemis (-)

: enlargement of lymph node (-) JVP PR 2 cmH2O Chest (Thorax) : Cor: Inspection: ictus cordis unseen Palpation: ictus cordis palpable in ICS VI, 2 fingers lateral to MCL S Percussion: UB ICS 2 MCL S, LB ICS MCL S), RB PSL ICS D Auscultation: S1S2 single, regular, murmur (-)

Po : Inspection: simmetrical static, ssimetric dinamic Palpation: vocal fremitus

N N N N N N sonor sonor sonor sonor sonor sonor

Percussion:

Auscul: vesicular
+
+ +

Rhoncy Wheezing
-

+
+ +

Abdomen :

Inspection : distention (-) Auscultation: Bowel sound (+) normal Palpation: Tenderness (-), Liver/spleen unpalpable, Percussion: Tymphani

Extremity : edema

, -warm -

+ +
+ +

CBC (4/12/2013)
Parameter WBC %NEU %LYM %MONO %EOS %BASO #NEU #LYM #MONO #EOS #BASO RBC HGB HCT MCV MCH MCHC RDW PLT Results 3,48 71,0 11,9 10,0 2,5 0,3 2,47 0,41 0,35 0,09 0,01 2,58 6,07 20,8 80,7 25,9 32,1 16,5 182 Unit x103/L % % % % % x103/L x103/L x103/L x103/L x103/L x103/L g/dL % fL Pg g/dL % x103/L Referance range 4,10-11,00 47,0-80,0 13,0-40,0 2,0-11,0 0,0-5,0 0,0-2,0 2,5-7,5 1,0-4,0 0,1-1,2 0,0-0,5 0,0-0,1 4,5-5,90 13,50-17,50 41,00-53,00 80,0-100,0 26,0-34,0 31,0-36,0 11.60-14,80 150,0-440,0 Low Low Low Remarks

Low High

Blood chemistry (7/12/2013)

Parameter Results Units Referance range Remarks

BUN
Creatinin

27
7,40

mg/dL
mg/dL

8,00 23,00
0,70 1,20

High
High

Hiperuricemia GFR : (140-36) x 50 x 0,85 = 8, 3 kg/1,73mm2 72 x 7,40

Blood gas analysis (25/11/2013)

Parameter Results Units Referance range Remarks

pH pCO2 pO2 HCO3TCO2 BE(B) SO2c Natrium Kalium

7,35 30 113 15,5 16,4 -9,4 98

MmHg MmHg mmol/L mmol/L mmol/L %

7,35-7,45 35,0-45,0 80,0-100,0 22,0-26,0 24,0-30,0 (-2) 2 95-100 135,0-145,0 3,5-5,10 High High High Low Low Low

134,00 mmol/L 5,5 mmol/L

Thorax photo PA ( 4/12/2013)

Cor : bigger, CTR 55% Pulmo : shows fibroinfiltrate in right suprahillar infiltrate left paracardial Sharp right and left pleura sinuses. Normal right and left diaphragma Bones: show no deformities. conclusion : cardiomegaly Lungs inflammation suspect specific process dd/ pneumonia

BOF photo
- theres no radioopaque shadow in urinary tract -symmetrical contour of right and left kidneys -Psymmetrical right and left psoas lines -Intestinal gas distribution increases mix with fecal material -Liver and spleen shadow bigger -Corpus, pedcledan spatium intervertebralis is normal -IUD insertion in cavum pelvis conclusio : -Meteorismus -Theres no radioopaque stone in all urinary tract -theres no deformity of bone

Electrocardiography (ECG)
Irama : Sinus Rhytem HR 96x/mnt, Reguler Axis Normal P wave Normal PR Segment Normal QRS complex Rv2+Sv5 35mm ST Segment Normal T wave Normal conclusion : NSR + LVH + HR 96x/mnt

Working Diagnosis
Chronic Kidney Disease Stage V ec susp GNC dd PNC Metabolic acidosis Hyperkalemia Moderate anemia sedang normokromik normositer on CKD (6,07) Hyperuricaemia Hypertension grade I - Cardiomegali e.c suspek HHD HCAP (improved)

Planning : therapy
Hospitalized IVFD NS 8 dpm Igh calori diet 35 kkal/kgBBday + 1,2 gram protein/kgBB/day (post HD Cito) Hemodialisis CITO has been done PRC transfusion untill > 9 g/dL has been done Ciprofloxacin 2x200 mg Amilodipin 1x 5 mg Captopril 2x25 mg Paracetamol 3x500mg (if axillary temp 38oc) Ambroksol syr 3x CI CaCO3 3x500 mg IO Folic acid 2x2mg IO

Planning Diagnostic
CBC, Echocardiography, sputum culture, sensitivity test

Monitoring
Symptoms Vital sign Signs of respratory failure Signs of decrease of consciousness Signs of heart failure Intake and output fluid BGA + electrolyte everyday untill matabolic acidosis treated

CIE
1. High calori and low protein diet for CKD patient, and limitation of fluid intake 2. Routine control to hospital to know the progresivity of the disease and having hemodialysis routinely to improve symptoms of CKD.

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