Venndiag Edema

FINAL CASE
CHRONIC KIDNEY DISEASE

Advisor: dr. Triharnoto, MBA, MSc., SpPD

Presented by:
Maria Mayella Vianney 2010 061 105
Parmadi Komalajaya 2010 061 168

PATIENTS IDENTITY
Name : Mr. P
Age : 49 years old
Marital status : Married
Address : Gundengan Lor RT 01/05
Magorejo Tempel
Religion : Catholic
Race : Javanese
Education : S1
Occupation : PNS
Date of admission : September 21
st
2011, 07:30
Date of examination : September 22
nd
2011

STEP 1: DEFINE THE CHIEF
COMPLAINTS
Male, 49 years old come with edema since 1 day
before admission.

STEP 2: DRAW A VENNDIAG AND FILL IT
WITH POSIBBLE DISEASE
Cardiac
Renal
Hepatic Metabolic
Others
EDEMA
Nephrotic syndrome
Acute nephritic syndrome
Renal failure
Cirrhosis
Congestive heart failure
Medication
Hypothyroidism
Severe malnutrition
1. Ferri, FF. 2006. Ferris Differential Diagnosis : A Medical Guide to the
Differential Diagnosis of Symptoms, Signs, and Clinical Disorders. 2
nd

eds. Philadelphia : Mosby Elsevier.
2. Fauci, Anthony S. 2009. Harrisons Manual of Medicine. 17
th
eds.
STEP 3: MAKE A BRIEF LITERATURE
REVIEW OF EACH DISEASE
C1. Congestive heart failure
R1. Nephrotic syndrome
R2. Acute nephritic syndrome
R3. Renal failure
M1. Hypothyroidism
M2. Severe malnutrition
H1. Cirrhosis
O1. Medication
RENAL

CARDIAC

HEPATIC

METABOLIC

OTHERS
NEPHROTIC SYNDROME
Comprises four distinct elements:
Edema
Massive proteinuria (urine protein:creatinine ratio >2)
Hypoalbuminemia
Hypercholesterolemia

Etiology
Minimal change nephrotic syndrome (MCNS)
Focal segmental glomerulosclerosis (FSGS)
Membranous nephropathy (MN)
Membranoproliferative glomerulonephritis (MPGN)
Physical findings and clinical presentation
Painless and symmetric edema

Laboratory tests
Protein:creatinine ratio >2 in the first morning urine specimen
Level of protein in excess of 1 g/m2 per 24 hours in 24 hours
urine collection
Hypoalbuminemia, hypercholesterolemia
Hipocalsemia
Hyponatremia
Elevated C3 level

Biopsy
nd

th
eds.
ACUTE NEPHRITIC SYNDROME
Hematuria
Proteinuria
Hypertension

Differential Diagnosis of Symptoms, Signs, and Clinical Disorders.
2
nd
th
eds.
RENAL FAILURE
A progressive decrease in renal function (CFR <60 ml/min for >3
month) with subsequent accumulation of waste products in the blood,
electrolyte abnormalities, and anemia

Etiology
Diabetes
Hypertension
Chronic glomerulonephritis
Polycystic kidney

The clinical presentation varies with the degree of renal failure and its
underlying etiology. Common symptoms are:
Generalized fatigue
Nausea, anorexia
Skin pallor, pruritus
Edema
Hypertension

Laboratory tests
Urinalysis: may reveal proteinuria, RBC casts.
Serum chemistry: elevated BUN and creatinine, hyperkalemia,
hyperuricemia, hypocalcemia, hyperphosphatemia,
hyperglycemia, decreased bicarbonate.
Imaging studies
Sonographic evaluation of the kidneys reveals smaller kidneys
with increased echogenicity in CRF.
2
nd
th
eds.
CONGESTIVE HEART FAILURE
Heart's inability to pump sufficient oxygenated blood to meet the
metabolic needs of the tissues

Framingham Criteria( 2 major / 1 major + 2 minor)
Major criteria
1. PND and OP
2. Increased JVP
3. Cardiomegaly
4. Acute pulmonal edema
5. S3 gallop
6. Rales
7. Hepatojugular reflux

Minor criteria
1. Edema
2. Nocturnal cough
3. Dyspnea deffort
4. Hepatomegaly
5. Pleural effusion
6. Decreased VC <1/3max
7. Tachycardia

Laboratory tests
Beta-type natriuretic peptide (BNP) is a cardiac neurohormone
specifically secreted from the ventricles in response to volume
expansion and pressure overload
Imaging studies
Chest x-ray
Pulmonary venous congestion
Cardiomegaly with dilation of the involved heart chamber
Pleural effusions
Electrocardigraphy
LV hypertrophy or a prior MI
nd

th
eds.
CIRRHOSIS
Cirrhosis is defined histologically as the presence of fibrosis and
regenerative nodules in the liver.

Etiology
Alcohol abuse
Viral hepatitis
Drug induce (e.g., acetaminophen, isoniazid, methotrexate,
methyldopa)

Jaundice
Palmar erythema
Fetor hepaticus
Gynecomastia
Small and nodular liver, ascites
Flapping tremor

Laboratory tests
Elevated serum SGPT and SGOT
Elevated serum bilirubin
Elevated prothrombin time
Hypoalbuminemia

Imaging studies
USG
CT scan to detect mass lession

2
nd
th
eds.
HYPOTHYROIDISM
Etiology
Hashimoto's thyroiditis
Previous treatment of hyperthyroidism (radioiodine therapy,
subtotal thyroidectomy)
Radiation therapy to the neck (usually for malignant disease)
Iodine deficiency or excess
Drugs (lithium, PAS, sulfonamides, phenylbutazone, amiodarone,
thiourea)

Fatigue, weakness, lethargy
Constipation
Weight gain
Cold intolerance
Nonpitting edema in skin of eyelids and hands
Thyroid gland: may or may not be palpable (depending on the cause of the
hypothyroidism).
Laboratory test
Increased TSH
Decreased free T
4

2
nd
th
eds.
MALNUTRITION
Decreased protein intake during stress state

Hair pluckability
Edema
Skin breakdown
Poor wound healing.

Larboratory tests
Decreased serum albumin (<2.8 g/dL)
Decreased transferrin (<150 mg/dL)
Decreased iron-binding capacity (<200 g/dL).
Cellular lack of response to skin test antigens (anergy).
2
nd
th
eds.
MEDICATION
Mechanisms include:
Renal vasoconstriction (NSAIDs and cyclosporine)
Arteriolar dilatation (vasodilators)
Augmented renal Na
+
reabsorption (steroid hormones)
Capillary damage (interleukin 2
nd

th
eds.
STEP 4: SCAN ON PATIENTS SIGN
AND SYMPTOMS
Male, 49 y.o came with edema since 1 day
before admission.
The edema is generalized, the patient
didnt notice any localization before.
This is the first time edema happened.
Patient also experience shortness of breath
and fatique. The shortness of breath and
fatique felt at the same time as the edema
started. Patient never experience any sleep
disturbances cause by shortness of breath
at night
There is a history of weight loss
EXCLUDE M1

C1. Cardiac dysrythmia
C3. Myocardial infarct
M1. Tyrotoxicosis
M2. Anemia
M3. Diabetic Ketoacidosis
N1. Guillain Barre Syndrome
N2. Spinal cord injury
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
PAST MEDICAL HISTORY:
Patient never took any medication before
EXCLUDE O1
Patient had admitted to hospital
before (October 2010) due to
stroke
There is a history of uncontrolled
hypertension R3
There is a uncontrolled diabetes
mellitus since 1997 R3
Patient has asthma since his young
ages
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
PHYSICAL EXAMNINATION
General condition : moderately ill
Level of consiousness: full alert
Vital Signs
Blood Pressure : 160/100 mmHg
(hypertension)
Pulse Rate : 96 beats/minute
(regular, strong, and full)
Respiratory Rate : 21 x/minute
Temperature : 36,8
o
C
Body weight : 52kg
Body height : 160 cm
BMI: 20,3 kg/m
2
(normal) EXCLUDE M2

P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
HEAD
No deformity and abnormality on face,
skull, scalp

EYES
Conjunctiva anemic +/+
Sclerae icteric -/- EXCLUDE H1

EAR
Discharge -/-
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
NOSE
Normal nasal septum

MOUTH
Wet oral mucosa

NECK
JVP: 5+1 cm H2O EXCLUDE H1, C1

SKIN
Jaundice EXCLUDE H1
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
CHEST (LUNG)

Inspection
Right lung movement is slower than left
lung movement

Palpation
Right lung compliance is slower than left
lung compliance

Percussion
Dull in basal right lung
Sonor in left lung

Auscultation
Lower lung sound in basal right lung
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
BACK

Inspection
Right lung movement is slower than left
lung movement

Palpation
Right lung compliance is slower than left
lung compliance

Percussion
Dull in basal right lung
Sonor in left lung

Auscultation
Lower lung sound in basal right lung
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
CHEST (COR)

Inspection
Point of maximum impulse was unseen

Palpation
Point of maximum impulse was palpable at 5
th

left ICS midclavicular axillary line

Percussion
Upper border 3
rd
ICS
Left border 5
th
ICS left midclavicular line
Right border 4
th
ICS right sternal line

Auscultation
Normal heart sound at all valve, no pathologic
heart sound

P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
ABDOMEN

Inspection
Flat, no visible lesion

Palpation
No pain at any abdominal region, undulation +
Liver palpable at 8 cm below arcus costae
Spleen not palpable
Kidney Ballotement -/-

Percussion
Asices +

Auscultation
Bowel sound 12x/minute
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
EXTREMITIES
Eutrofi, normotonus
Edema superior +/+
Edema inferior +/+
CRT<2s

GENITALIA
Not checked
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
RESUME
Male, 49 y.o came with edema since 1 day before
admission. The edema is generalized, the patient
didnt notice any localization before. This is the first
time edema happened.
Patient also experience shortness of breath and
fatique. The shortness of breath and fatique felt at
the same time as the edema started.
Patient had history of stroke, uncontrolled
hypertension, and uncontrolled diabetes mellitus.
From the physical examination:
Hypertension
Anemia
Cardiomegaly
Basal right pleural efussion
Acites
Hepatomegaly
Superior and inferior extremity edema

STEP 5: MAKE WORKING
DIAGNOSIS

NEPHROTIC SYNDROME
ACUTE NEPRITIC SYNDROME
RENAL FAILURE
P1. Obstruction
P1A. COPD
P1B. Asthma
P2. Infection
P2A. Pneumonia
P2B. Tuberculosis
P2C. Bronchiectasis
P3. Neoplasm
P4. Pneumothorax
M1. Tyrotoxicosis
M2. Anemia
O1. Fractured ribs
O2. Sepsis
R3. Renal failure
M1. Hypothyroidism
H1. Cirrhosis
O1. Medication
STEP 6: DEFINE INITIAL
TREATMENT
Measure O2 saturation. If SaO2 90% administer
supplemental O2 3-4 lpm per nasal canule
Furosemide 40 mg IV
Catheter
ECG
Chest X-Ray
Complete blood count
Liver function test
Renal function test
Blood gas analysis
Urine analysis
STEP 7: MAKE FURTHER
INVESTIGATION
September 21
th
2011
Hematology
Hemoglobin:7,8 mg/dL (12-16,5)
Hematocryte: 24% (37-47)
Erythrocyte: 2,73 million/ mm
3
(3.8-5.8)
Thrombocyte: 242.000/mm
3
(150.000-450.000)
Leukocyte: 6.600 /mm
3
(4.000-11.000)
Differential count
Eusinophil: 0,3% (0-9,5)
Basophil: 1,2% (0-2,5)
Neutrophil: 81,8% (35-88.7)
Lymphocyte: 11,2% (12-44)
Monocyte: 5,5% (0-11,2)
MCV: 87,9 fl (80-96)
MCH: 28,6 pg/sel (27-31)
MCHC: 32,5 g/dL (32-46)
RDW-CV: 16,4% (11,6-14,8)

Liver function
SGOT: 20,1 U/L (0-32)
SGPT: 21,6 U/L (0-31)
Total protein: 4,81 g/dL (6-8)
Albumin: 3,03 g/dL (3,4-4,8)
Globulin: 1,78 g/dL (3,2-3,9)
PT: 14,1 detik (12,7-15,4)
APTT: 35,6 detik (37,9)
Kidney function
Ureum: 270 mg/dL (10-50)
Creatinine: 14,56 mg/dL (0,5-0,9)

Electrolyte
Sodium: 135 mmol/L (136-145)
Potasium: 6,5 mmol/L (3,3-5,1)
Chloride: 115 mmol/L (98-106)

Chest x-ray
Mild cardiomegaly with lung edema, supporting ec renal
failure
Right pleural effusion

ECG
Normal sinus rhythym

STEP 8: MAKE DEFINITIVE
DIAGNOSIS
HISTORY
Male, 49 years old come with
generalized edema that
happened at the same time with
shortmess of breath and fatique
since 1 day before admission
Sleep disturbances cause by
dyspnea at night (-)
Weight loss (-)
Medication (-)
Hypertension (+)
Diabetes mellitus (+)
Stroke (+)

PHYSICAL EXAMINATION
Hypertension
Anemia
Cardiomegaly
Basal right pleural efussion
Acites
Hepatomegaly
Superior and inferior extremity
edema
LABORATORY RESULTS
Anemia
Hipoproteinemia
GFR: [(140 age) x BB]
(72 x creatinine plasma)
: [(140 49 ) x 52]
(72 x 14,56)
: 4,51 ml/minute
Hiponatremia
Hiperkalemia
Hiperchlorida

Normal ECG

Chest X-Ray
Mild cardiomegaly
with lung edema
supporting ec renal failure
Right pleural effusion

NEPROTIC SYNDROME
ACUTE NEPRITIC SYNDROME
RENAL FAILURE
STEP 9: DEFINE CAUSATIVE TREATMENT

Fauci AS, dkk. Harrisons Manual of Medicine 17
th
Edition. 2009
DIAGNOSTIC APPROACH
1. Renal disease
Generalized edema
Albumin: 3,03 g/dL
JVP: 5+1 cm H2O
Ureum: 270 mg/dL
Creatinine: 14,56 mg/dL

Chronic kidney disease (CKD)
Kidney damage at least within 3 months or more which
defined as structural or functional abnormality with or
without any decrease of glomerulofiltration rate (GFR)
which manifested as pathological abnormality or kidney
damage, including imbalance blood or urinary subtance
with or without any abnormality in imaging studies.

GFR < 60ml/minute/1,73 m
2
for more than 3 months
without any kidney damage.

Perhimpunan Nefrologi Indonesia. Konsensus Dialisis. Jakarta: 2003
Chronic kidney disease stage 5

Fauci AS, dkk. Harrisons Principles of Internal Medicine 17
th
Edition. 2009

Stage GFR (ml/minute/1,73m
2
)
0 >90 with CKD risk factor
1 90 with CKD symptomps
2 60-89
3 30-59
4 15-29
5 <15
2. Hypertension stage 2

JNC 7 Express
Systolic (mmHg) Diastolic(mmHg)
Normal <120 and <80
Prehypertension 120-139 or 80-90
Hypertension stage 1 140-159 or 90-99
Hypertension stage 2 160 or 100
TREATMENT
Stage GFR (ml/minute/1,73m
2
) Treatment*
1 Kidney damage with
normal or increase GFR
90 Treat comorbid disease
and slow the progression
2 Kidney damage with
mild decrease GFR
60-89 Estimate the progression
3 Moderate decrease GFR 30-59 Evaluate and treat the
complications
4 Severe decrease GFR 15-29 Prepare for kidney
replacement therapy
5 Renal failure <15 (or dialysis) Kidney replacement (if
theres ureamia)
*Include the therapies from previous stage

Fauci AS, dkk. Harrisons Principles of Internal Medicine 17
th
Edition. 2009.

Life style
modification
Medication
No indication Indication
Normal Motivate
-
Based on
indication
Prehypertension Yes
Hypertension stage
1
Yes T
ACEI/ARB/ BB/CBB
Based on indication.
Add T,
ACEI/ARB/BB/CBB
as needed.
Hypertensi onstage
2
Yes T +
ACEI/ARB/BB/CBB
JNC 7 Express

JNC 7 Express

STEP 10: SHOW CLINICAL COURSE
OF THE DISEASE

Diabetes
mellitus
Dialysis
Hypertension
Renal
vasoconstriction
Ischemia
Kidney
damage
Renal
failure
DEATH

Venndiag Edema

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FINAL CASE

CHRONIC KIDNEY DISEASE

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