Department of Internal Medicine

Faculty of Medicine Sultan Agung Islamic University

2019

Case Based Discusion

Ainingtyas Marda Rizkani
30101407122
Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
Patient Identity

Name : Mrs. S
Age : 49 years old
Gender : Female
Religion : Moslem
Job : Farm
Address : DK Pilo RT 08 RW 4 Mojowetan banjarejo, Blora
RM number : 1375158
Room : Baitul Izzah 2 – A3
Entry date : March 15 th, 2019
Date out : March 19 th, 2019
History taking

Main Problem
• Limp

History of present illness

• Patient come as out patient to the clinic on Sultan Agung Islamic
hospital with a limp complaint. Patients felt this all day long.
Patients were previously treated at the Dr. r. Soetijono Blora
hospital for 1 weeks before they arrived at the hospital. The patient
also feels abdominal pain especially on the left, nausea, tingling
and swelling in the legs. The patient does have history of DM and
HT.
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
SOSIO-ECONOMIC HISTORY :
Hypertension history (+)
Hospital cost certified by
DM history (+)
“BPJS-PBI”
Asthma history (-)
Alergy history (-)
SMOKING (-)
Uric Acid (-)
FAMILY’S HISTORY OF DISEASE

Hypertension history (-)

DM history (+)

Asthma history (-)

SISTEMIC ANAMNESIS
Complains : Limp

Onset : 2 weeks ago

Location : Abdomen

Chronology : Patient was having on several weeks hat does not heal
after treated at the Dr. r. Soetijono Blora hospital

Quality and Quantity : Limp was coming everyday

Modification factor : Better when she took a rest

Comorbid complains : abdominal pain especially on the left, nausea,

tingling and swelling in the legs
 PHYSICAL EXAMINATION
General : composmentis Throat : pain swallow(-), hoarseness (-),
Skin : itching (-), jaundice (-), pale (-) odinifagia (-)
Neck : enlargement of the gland (-)
Head : headache (-)
Chest : cough (-), sputum (-), blood (-)
Eyes : blurred vision (-), red eyes (-),
Cardiac : chest pain (-), palpitations (-)
icteric sclera (-/-)
Digestive : abdominal pain (+), nausea (-),
Ears : hearing loss (-), ring (-), vomiting (-)
discharge (-) Musculoskeletal : weak (-), rigid (-), back pain (-)

Nose : nosebleed (-), discharge (-) Extremity : oedem extremity (-)

Mouth : cyanosis (-), thrush (-),

bleeding gums (-)
GENERAL STATUS
BMI (Body Mass Indeks)
weight : 55 BMI= 55/(1,5 x 1,5) = 24,44
High : 155
Intepretation :
Normoweight

General : Limp
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
• Blood Pressure : 150/90 mmHg
• Heart rate : 82 x/minute
• Breath Frequency : 22 x/minute
• Temp : 36,5oC
Intepretation :
Hypertension grade 1
GENERAL STATUS
Head : Mesocephal, alopesia (-)

 Eyes : Anemic Conjuntiva(-/-),Icteric sclera(-/-)

 Nose : symmetric, secret (-), Nostril Breath (-)

 Ears : Normal Shape, discharge (-/-)

 Esophagus : Hyperemic (-), pain devour (-)

 Mouth : Cyanosis (-), dry lips (-),

 Neck : Trakhea deviation (-), Lymph Hypertropy (-)

 Extremity : Oedem of lower extremity / upper extremity (+) / (-)

Intepretation : oedem of
lower extremity
LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL

Dynamic Up and down of hemitoraks D=S, Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle abdominothorakal breathing (-),
retraction of breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)

Palpation Palpable pain(-), tumor (-), Arcus costae Palpable pain (-), tumor (-), Arcus
angle < 900, enlargement of ICS (-), Stem costae angle < 900, enlargement of
fremitus D=S ICS (-), Stem fremitus D=S

Percution Dull sound Dull sound

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-), Intepretation :
Ronchi (-) NORMAL
CARDIAC EXAMINATION
Inspection : Ictus cordis isnt seen.

Palpation : thrill (-), epigastric pulse (-), parasternal pulse (-),

sternal lift (-).

Percussion : dull sound

 Upper borderline of heart : ICS II left sternal line
 Waist of heart : ICS III left parastern line
 Lower right borderline of heart : ICS V right sternal line
 Lower left borderline of heart : ICS VI, 2 cm lateral from left
mid clavicle line
Intepretation :
Cardiomegali
 ...CONT

Auscultation
 Aortal valve : S1 & S2 standard, additional sound (-)

 Pulmonary valve: S1 & S2 standard, additional sound (-)

 Tricuspid valve : S1 & S2 standard, additional sound (-)

 Mitral valve : S1 & S2 standard, additional sound (-)

Intepretation : NORMAL
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
Intepretation : abdominal pain +
caputmedusa (-). epigastric +, pain on
costovertebral +
Auscultation : peristaltic (+)
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (+)
• Deep : abdominal pain (+), liver, kidney, and spleen weren’t
palpable, Murphy’s sign (-)
Percussion : tympani, side of deaf (-), shifting dullness (-)
• Liver : deaf(+), right liver span 10 cm, left liver span 6 cm
• Spleen : Throbe space percussion (+)  tympani
• Kidney : pain tap on costovertebral (+)
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior

• Oedema -/- +/+

• Cold -/- -/-

• Jaundice -/- -/-

Laboratorium Examination
 08/03/2019 11/03/2019 15/03/2019 19/03/2019 Normal values
Renal function :
-Uric Acid - 9,6 mg/dL (H) - - 7 mg/dL
(Perempuan)
-Ureum 79 mg/dL (H) 82 mg/dL(H) 72 mg/dL (H) 61 mg/dL (H) 10-50 mg/dL
-Blood Creatinin 4.79 mg/dL(H) 4.09 mg/dL(H) 4.10 mg/dL (H) 3.15 mg/dL (H) 0.6-1.1 mg/dL
- Total protein - - 4.82 g/dL (L) - 6.0-8.0 g/dL
Albumin - - 2.84 g/dL (L) - 3.4-4.8 g/dL
Globulin - - 1.98 g/dL
SGOT - - 14 - 0-35 U/I
SGPT - - 18 - 0-35 U/I
Hematologi
-Haemoglobin 9.8 g/dL (L) 5.8 g/dL (L) 9,7 mg/dL (L) - 13.2-17.3 g/dL

-Hematocrit 32.2 % (L) 18.2 % (L) 30.8% (L) - 33-45 %

-Leukosit 8.7 ribu/dL 3.13 ribu/dL(L) 6.78 ribu/dL - 3.8-10.8 ribu/dL
-Trombosit 281 ribu/dL 113 ribu/dL (L) 337 ribu/dL - 150-440 ribu/dL
 08/03/209 11/03/2019 15/3/2019 19/03/2019 Normal values
Electrolit
-Natrium 129.1 mmol/L 137.8 mmol/L - - 135-155 mmol/L
-Kalium 4.13 mmol/L 5.83 mmol/L (H) - - 3.5-5 mmol/L
-Chloride 96,8 mmol/L 107.7 mmol/L - - 95-108mmol/L
Glucosa function: - -
-GDS 279 mg/dL 286 mg/dL - - 70-180 mg/dL
Interpretation

 ↑ Uric Acid (hiperuricemia)

 anemi
 Hiperkalemi
 Azotemi
 Hiperglikemi
 hipoalbumin
EKG
 Interpretasi EKG

Rhytm : Sinus
Regularity : Regular
Frequency : 1500/18 = 83 bpm
Axis : NAD
Transisional zone : -
P wave : wide : 0,08 s; height : 1 mv
PR interval : 0,20 s
QRS complex : 0,08 s
Q wave :-
S wave : height in V1 < 40 mV
ST segment : normal,there is no elevation and depresion
T wave : T flat (-),T tall (-), T inverted (-)
USG Examination
Chest X-Ray
 Abnormal Data USG :
7. Multiple
Cholesistolithiasis

History Taking Physical

Lab
1. Limp, 2. nausea, Examination
8. ↑ Uric Acid (hiperuricemia)
3.abdominal paint , 4. 6.High blood 9. ↑ Ureum (Azotemia)
10. hipoalbumin
tingling, 5. pressure : 150/90
11. ↓ Haemoglobin (Anemia)
12. hyperkalemi
13. hyperglikemi
1Problem List
CKD (1,2,3,4,5,7,8,9)
3 Hipertensi (5)

2 DM (13)
4 Anemia (10,11)

5
6
hypoalbumin
hyperkalemi

7 hyperuricemi
8 cholelithiasis
  Assassement : emergency condition  to prevent metabolic acidosis,
hyperkalemia, bleeding, crisis hypertention, over hidration, infection.
CKD  IP Dx : BGA
 IP Tx :
 Non pharmacologic :
 Limitation of protein intake :
- Pre dialysis (0.6-0.75/kgBB/day)
- Hemodialisis : 1,2 g/kgBB/day
- Dialisis peritoneal : 1,2-1,3 g/kgBB/day
 Calorie Intake 30-35 kkal/kgBB/day
 Dialysis
 Diit low protein (0,6- 0,8 grKgBB/day)
 Pharmacologic :
 CaCO3 3x1
 Folic acid 15 mg
 IP Mx
 IP Ex
 Explain to the patient about the disease
 Explain about dialysis
 Take medicine regularly
 Explain side effect of medication
 Explain about proper daily intake, including type of diet and food
 Routine Control of Blood Pressure
DEFINITION AND CLASSIFICATION (KDOQI)
 Kriteria CKD (terjadi lebih dari 3 bulan)
Penanda kerusakan ginjal (1 - Albuminuria (AER ≥ 30mg/24
atau lebih) jam; ACR ≥ 30mg/g (≥3
mg/mmol)
- Abnormalitas sedimen urin
- Abnormalitas elektrolit atau
lainnya yang berkaitan
dengan gangguan tubulus
- Abnormalitas struktur yang
dideteksi dari radiologi
- Riwayat transplantasi ginjal
Penurunan laju filtrasi GFR < 60 ml/menit/1,73 m2
glomerulus (GFR)
Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( )
𝑑𝐿
140−49 𝑥55 (𝑘𝑔)
= 𝑚𝑔
72𝑥4.79( )
𝑑𝐿
5,005 Chronic Kidney
= = 14,51
344,88 Disease Grade V
 Old Classification of CKD as Defined by Kidney Disease
30 Outcomes Quality Initiative (KDOQI) Modified and Endorsed
by KDIGO
Stage Description Classification Classification
by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

Note: GFR is given in mL/min/1.732 m²

KDIGO, Kidney
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Disease: Increasing
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266 Global Outcomes
Rencana Tatalaksana Penyakit Ginjal Kronik sesuai
dengan derajatnya (Sudoyo, 2014)

Derajat LFG (mlmnt/1.73 m2) Rencana tatalaksana

1 ≥ 90 Terapi penyakit dasar, kondisi komorbid,
evaluasi perburukan (progression) fungsi
ginjal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression)

fungsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 Kidney Disease: Improving Global Outcomes
(KDIGO) CKD Work Group. Kidney Int Suppls.
2013;3:1-150.
 Indikasi hemodialisa
Hemodialisis segera atau
emergency
• Uremia ( BUN >150mg/dL)
• Oliguria (urin < 200ml/12jam)
• Anuria (urin < 50ml/ 12jam)
• Asidosis berat (pH < 7.1)
• Hiperkalemia
• Ensefalopati uremikum
• Neuropati Uremikum
• Hipertermia
• Disnatremia (Natrium > 160
atau < 115 mmol/L)
Hemodialisis kronik, yaitu
hemodialisis yang dilakukan
seumur hidup
• Dimulai apabila dijumpai
salah satu gejala yaitu :
• a. LFG < 15ml/menit,
tergantung gejala klinis
penderita
• b. Malnutrisi atau hilangnya
massa otot
• c. Gejala uremia antara lain
anoreksia, mual muntah,
lethargy
• d. Hipertensi yang susah
dikontrol
• e. Kelebihan cairan
 KOMPLIKASI
36
37 NUTRISI PADA PASIEN CKD :
KOMPOSISI MAKRONUTRIEN DAN MINERAL

Adapted from DASH (dietary approaches to stop hypertension) diet.

*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as
fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water
fish, and poultry.

*(CKD Stages 1-4)

NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-
S179.
DM tipe 2

 Assesment 1. Humalog 3 x 6 U SC
Komplikasi akut : Hipoglikemia
Komplikasi Kronis : Makroangipati  Ip. Mx :
(PJK, CVD, peripheral atrial disease,
1. Vital sign
cerebral arterial disease)
Mikroangiopati (retinopati, nefropati, 2. Kadar GDS/GDP/GD2PP
disfunction erection, neuropati)
 IP Dx :  Ip. EX :
GDP, GDPP, dan HbA1C 1. Menjelaskan pengertian DM
Coronary arteriography, CT scan, ABPI 2. Mengajarkan cara pemantauan GDS
(<0,9), funduscopy, microalbuminuria mandiri
test/micral test, EMG
3. Edukasi tanda-tanda hipoglikemi dan
 IP Tx : cara mengatasi
Non Farmakologi : Management lifestyle 4. Mengurangi konsumsi makanan dengan
TGM kadar gula
Indication of insulin usage

 DM type 1
 Underweight
 Severe hyprglicemic with ketosis
 Ketoasidosis diabeticum
 Hyperosmolar non ketotic
 Hyperglicemi with lactate acidosis
 Not respond with hyperglycemic oral. (reason in this patient)
 Severe stress
 Gestational DM
 Dysfunction of renal function . (reason in this patient)
 OHO’s allergic
Hypertension
Grade I  Assassement : Stroke, retinopati hipertensif, LVH
 IP Dx : ct scan, funduscopi, Chest X-Ray
 IP Tx :
Non Pharmacologic
 Lowering salt intake on 6 g/day of NaCl

Pharmacologic
 candesartan 8 mg 1x1

 IP Mx :
 Vital Sign(Blood Presure), General state, Awareness
 IP Ex
 Explain about Hipertension
 Motivating to change into better lifestyle (include more activity 3-4 days a week,
low sodium diet, and high fiber diet)
 Take medication regularly
Hiperurisemia
Assassement :
High intake of purin, metabolism disorder, excretion disorder
 IP Dx :
 IP Tx :
 Pharmacologic
 Allopurinol 100 mg 2x1
 IP Mx
 Level of Uric Acid, Pain,
 IP Ex
 Avoid Organ meats high in purine contains ( liver, kidney,
seafood)
 Avoid sweetened soda beverage
 Do Excercise
a
Anemia  Assasement : anemia mikrocytic hipochromic, anemia normositic
normochromic, anemia makrositic
 IP Dx : eritrocyte morphology examination (MCV, MCH, MCHC), complete
blood count
 IP Tx :
 Non pharmacological : PRC tranfsusion 2 colf
 Pharmacological : Folic Acid 1x1,
EPO preparat
 IP MX
 General state, Awareness, Vital Sign, Routine blood (Hb, Ht), reaction
transfusion, sign of overhidration
 IP Ex
 Explain about Anemia
 Explain about treatment of anemia
 Explain about side effect of anemia’s treatment
Hiperkalemi
 Assassement : Cardiotoxic, Metabolic acidosis
 IP Dx : ECG,BGA
 IP Tx : Hemodialysis, dietary restriction
 IP Mx
 General state, Awareness, ECG, Vital Sign, kalium status
 IP Ex
 Explain about disease
 Explain about treatment and side effect
Hipoalbumin

 Assassement : -
 IP Dx : -
 IP Tx :
 HAS (Human albumin solution)
 IP Mx :Vital Sign, albumin status
 IP Ex :
 Explain about disease
 Explain about treatment and side effect
Rumus :
0,8 x BB X (3,5-A)= … gram

0,8 x 55 x (3,5-2,8)
=40 x 0,7= 28 gram
Cholelitialisis

 Assassement : Cholecystitis
 IP Dx :USG, CT scan
 IP Tx :
ERCP (Endoscopic retrograde cholangiopancreatography)
Laparoscopic cholecystectomy
Terapii: asam urodeksikolat 10-15mg/kgBB/hari

 IP Mx :Vital Sign
 IP Ex :
 Explain about disease
 Explain about treatment and side effect
Liver secretion and
gallbladder
emptying
 PENUNJANG LABORATORIUM
DIAGNOSTIK

IMAGING Non-invasive
• Radiography / FPA
• Oral cholecystography
• Radionuclide imaging
Invasive • Ultrasound
• ERC(P) • Computed Tomography
• Operative Cholangiography • Magnetic Resonance
• T-tube cholangiography Imaging (MRI – MRCP)
• PTC
ENDOSCOPIC RETROGRADE
CHOLECYSTOPANCREATOGRAPHY
= ERCP
 Dengan endoskopi/duodenoskopi ampulla Vateri dimasuki canula
 Kontras dimasukkan melalui canula
 Dapat juga untuk mengambil spesimen
 Dapat untuk terapeutik : mengambil batu dan memasang stent
ERCP = Endoscopic Retrograde Cholecysto
Pancreatography
ERC = Endoscopic Retrograde Cholangigraphy
Batu di CBD
PTC = Percutaneous Transhepatic
Cholangiography