CASE REPORT:Chronic Kidney Disease ec. Hypertensive Nephropathy

Rey Jauwerissa030.07.215

Lecturer : dr. Arif Gunawan, Sp.PD

Identity•Mr. WName •60 years oldAge •MaleSex•Sukamulya 02/02 KarawangAddress •LabourOccupation

•MoeslemReligion•MarriedMarital Status

•2 February 2012Date of Admission

•RengasdengklokTaken from

Picture Taken February 7th 2012

Main Complaint

Dyspnoe since 3 hours before hospitalized

swelling nausea

vomiting

Headache

FatigueLoss of

appetite

Additional Complaints

Mr W, a 61 years old man, came to RSUD Karawang emergency

room departement unit, due to dyspnoe since 3 hours before

hospitalized. The dyspnoe appeared suddenly, and became

worsen if he got layed down, and it got better in sitting position.

He also felt pulsative headache since 1 week before

hospitalized, which is located in the posterior part of head and

neck. Nausea and vommiting was also present, contained

recently eaten food, without any blood seen, and it was not

coffe-like coloured.fatigue and loss of appetite was also present.

History of present illness

One week before hospitalized he felt

swollen on all over his bodies, and mainly seen

on the face and both extremities. He denied had

any fever, cough and chess pain, stomache and

low back pain. He ussualy deffecated once a day,

solid consistency, without blood and slime. He

urinate yellow to colourless, clear, Without blood

and no pain

History of present illness

Patient never had the same symptoms before Hypertension (+) since 5 years ago, not

controllable DM (-) Food or drugs allergy (-) Cardiovascular disease (-)

Pulmonary disease (-) Liver disease (-) Gastrointestinal disease (-) Never been operated before

History of past illness

• Same illness before (-)• DM (-)• Hypertension (-)• Asthma / Allergic (-)• Cardiovascular / pulmonary disease (-)

History of family illness

Personal and Social History

Smoked history (+), 3 cigarettes a day Medication (-) Never drank any alcohol before Didn’t exercise regularly

PHYSICAL EXAMINATION

General appearance Moderately ill

Conciousness Compos mentis

Weight / Height 55 kg/160 cm

BMI 21,48

General Condition

General

Vital sign

Vital Sign

General

Head◦Normocephaly

Eyes◦Conjunctiva anemic (+/+)◦Sclera icteric (-/-)

Neck Lymph gland is not palpable Thyroid gland is not palpable JVP 5-2 cmH2O

Physical Examination

Head and Neck

• Inspection : Symmetrical movement of thorax

• Palpation : Symmetrical vocal fremitus

• Percussion : Sonor of bilateral hemithorax

• Auscultation : Vesicular breath sound in

both lungs, no ronchi and wheezing

Lung Examination

Thorax

• Inspection : Ictus cordis is not visible• Palpation : Ictus cordis is palpable at 5th ICS 1

cm medial of LMCS• Percussion : no heart enlagement • Auscultation: Regular I - II heart sound

no murmur and gallop

Heart Examination

Thorax

Inspection : ◦ Flat abdomen

Palpation : ◦ No abdominal pain◦ No liver and spleen enlargement

Percussion :◦ No pain present on abdominal percussion◦ Sounds tympani

Auscultation :◦ Bowel sound 4x/minute

Abdominal Examination

Abdomen

Extremity Examination

+ ++ +

•Warm acrals

•Oedema+ ++ +

Extremity

Laboratory ExaminationFebruary 2th 2012

Hb 4,3 12 – 17 g%

Leukocyte 12.200 5 – 10 rb

Trombocyte 220.000 150 – 450rb

Ht 14 37 – 48 %

Basofil 0 0 - 1

Eosinofil 0 1 - 3

Basil 0 2 - 6

Segmen 83 40 - 70

Lymphocyte 13 20 - 40

Monocyte 4 2 – 8

GDS 132 80 – 140 mg/dl

Ureum 247,1 10 – 45 mg/dl

Creatinine 15.05 0,4 – 1,5 mg/dl

Cockroft-Gault Formula

Creatinine Clearance

(140 – age) x Weight

Cr Serum x 724.06

February 2th 2012

Electrocardiography

ResumeSymptoms Signs Laboratory

and others• Dyspnoe (+)• Swelling (+)• Nausea and vomiting• Headache• Fatigue• loss of appetite

• BP: 210/100 mmHg• HR: 100 x/minute• T: 36,5oC• RR: 32 x/minute• Eyes : CA +/+• Oedem in both

extremities

• Hb 4,3 g%•Leukocyte 12.200• Ht 28 %• Ureum 247,1 mg/dl • Creatinin 15,05 mg/dl

•Creatinine Clearance 4,06

Chronic Kidney Disease ec hypertensive nephropathy

Chronic Kidney Disease ec. Nephrotic syndrome

Chronic Kidney Disease ec. Acute glomerulo nephritic

Acute kidney injury

Differential Diagnosis

Chronic Kidney Disease ec hypertensive nephropathy

Working Diagnosis

Chest X-ray Blood gas analysis Urinalysis Abdominal USG

Suggested Examination

Bed Rest High calories, low protein diet IVFD D5% 10 drops/min Prc transfussion Renxamin 1 fl / day Lasix 2 x 1 amp CaCO3 3x1 tab Asam folat 3x1 tab Captopril 25 mg 3x 1 tab Valsartan 1x 8 mg tab Amlodipin 1x1

Treatment

PRO- Hemodialysis

Suggested Treatment

PATIENTREFUSED

Ad Vitam Dubia ad bonam

Ad Functionam Dubia ad malam

Ad Sanationam Dubia ad malam

Prognosis