chronic kidney diseases, dm and gerd
TRANSCRIPT
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Duty Report Chronic Kidney Diseases, DM
and GERD :Approach of complexity problem
Supervisor : Dr .dr. Soroy Lardo, Sp.PD FINASIMIrnanita Pratiwi
Maharani Falerisya NDivision Infectious Diseases and Tropical Medicine
Department of Internal Medicine Indonesian Army Central Hospital Gatot Soebroto
Faculty of Medicine UPN Veteran Jakarta
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Patient’s Identity
• Name : Tn. T• Age : 69 y.o• Address : Jalan Kayu Manis Baru Jaktim• Job : Army• Married
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Anamnesis
• Chief Complaint :Burning sensation and pain in abdominal since
one day before hospital
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History of recent illness • Patients was feel burn sensation and pain in abdominal since
a day before come to the hospital. The pain spread to the back, abdomen to the right inguinal. The pain was persistent
• Patient also feel weekness since a day ago and feel his leg swollen for this recent 1 month.
• Nausea and vommite (-), headache (-), Fever (-), Bloated (-), Dispnea (-), Palpitation (-)
• Urinate rarely, there’s no urine colors changes, no micturition pain
• normal defecation
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Past illness history
• Patient have diabetic and hypertension history since 5 years ago, he routinely check his illness to the internist. The doctor routinely check the renal function and found his creatinin serum was increase since 5 months ago, from 4 to 7.6 mg/dl
• The doctor recommend him for doing a hemodialisa
• 5 month ago he was hospitalize for a vertigo
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TREATMENT HISTORY• Amlodipine 1 x 5 mg• Glurenorm 30 mgFAMILY HISTORY• No one in his family with similiar problem• No history of Hypertension, Diabetic , Allergic
HABITS Smoking 1 pack a day since 20 years old until
50 years old
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Physical Examination • General state : moderate illness• Consiousness : Compos Mentis• Vital Sign Blood Pressure : 150/70 mmHgPulse : 80 x /minute, regularTemperature : 37,0oCRespiration Rate : 18x/minute
Body Weight : 77 kgBody Height : 172 cmBMI : 26 (Obesse I, Asian – Pacific perspective)
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• Head : Normocephal, normal head distribution• Eye : Pale Conjungtiva +/+, Sclera icteric -/-• Ear, Nose, Throat : no abnormalities• Mouth : Acetonic smell (+), Less oral hygine, pale muccosal (-)• Neck : on CDL in regio colli dextra, lymph node enlargement (-)• Thorax : Lungs
Inspection : normal chest shape, Symmetric while breathing, no retraction of intercostae spacePalpation : symmetric tactile fremitus, symmetric chest expansion Percussion : Resonant sound bilateraly (sonor)Auscultation : Vesicular breathing sound bilaterally (+), Rhonki (-), Wheezing (-)
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• Heart :Inspection : No visible ictus cordisPalpation : Ictus cordis at ICS 5 linea midclavicula sinistraPercussion : -Left margin : ICS V linea left midsternalis-Right margin : ICS V linea left mid clavicle -Upper margin : ICS IV linea left parasternal Auscultation : Normal S1-S2 are heard, murmur (-), Gallop (-)
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• Abdomen : Inspection : normal countour, caput medusa (-)Auscultation : normal bowel movementPalpation : no palpable liver and spleen,no pain when palpating all abdomen region, normal turgorPercussion : tympanic in all area, Shifting dullness (-)
Extremitas : warm acral, Pretibial pitting edema (+/+), CRT <2s
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Laboratory Findings Complete blood tests Result Normal value
Hemoglobin 9,9 g/dl ↓ 12,0 - 16,0
Hematocrit 29 % ↓ 37,0 - 47,0
Erythrocyte 3,3 ↓ 4,30 – 6,0 juta
MCV 89 fL 80,0 – 96,0
MCH 30 g 27,0 – 32,0
MCHC 34 g/dl 32,0 – 36,0
Thrombocyte 150.000 150.000- 400.000
Leukocyte 13.030 ↑ 4800 – 10.000Diff count
Basophyle 0 0 - 1
Eosinophyle 0 1 – 3
Neutrophyle 79% ↑ 50 – 70
Limfocyte 10 % ↓ 20 - 40
Monocyte 7 % 2 - 8
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Blood metabolic
Ureum 154 mg/dl ↑ 20 – 50Creatinin 10,6 mg/dl ↑ 0.5 – 1.5Glucosse 245 mg/dl ↑ 70 - 100
Electrolyte
Natrium (Na) 138 135 - 147Kalium 3.8 3.50 – 5.00Chloride 108.0 95.0 – 105.0
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Urinalisis Result Normal Value
Color yellow yellow
Clearness Clear Clear
Berat Jenis 1,025 1,000 – 1,030
pH 5.5 5.0 – 8.0
Protein ++ negatif
Glucosse + negatif
Keton - Negatif
Blood +++ ( 250RBC/ul) Negatif
Bilirubin - negatif
Urobilinogen 0.1 0,1 – 1,0mg/dl
Nitrit - negatif
Leukocyte esterase - negatif
Leukocyte 1-1-1 <5 / LPB
Eritrocyte 1-2-2 <2 / LPB
Silinder Butir 0-1-0 -
Cristal - negatif
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Resume • Patients was feel burn sensation and pain in abdominal since a day
before come to the hospital. The pain spread to the back, abdomen to the right inguinal. Patients also feel weekness since a day ago and feel his leg swollen.
• Nausea and vommite (-), headache (-), Fever (-), Bloated (-), Dispnea (-), Palpitation (-), Urinate rarely , defecation normal
• Patient have diabetic and hypertension history, he routinely check the illness to the internist. The doctor routinely check the renal function and found his creatinin serum was increase since 5 months ago, from 4 to 7.6 mg/dl. The doctor recommend him to doing a hemodialisa
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• Phsycial examination shows anemic conjungtiva, asetonic smell, CDL on right colli region, Pretibial pitting edema bilateral
• Laboratory found decrease of Red blood cell component, Increase ureum and creatinin serum
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Problem list
• Burning sensation ec susp GERD • Abdominal Pain e.c susp. Urinary Tract Stones
dd/ UTI• Chronic Kidney Dissease• Hypertension• Diabetes Mellitus Type 2
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Problem Solving
1. Burn sensation ec susp GERD dd Diabetic Gastropathy
• An : burn sensation since a day before hospital. Nausea and vommite (-), diarrhea (-)
• PE : abdomen auscultation : normal bowel movement, palpation : pain (-)
• Diagnostic : endoscopy• Th : • Education : avoiding large meals and spicy food
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2. Abdominal Pain ec urinary track stones dd UTI• An: Abdominal pain spread to the back,
abdomen to the right inguinal• PE : Palpating pain (-)• Lab : Proteinuria ++, Hematuria +++• Diagnostic : Lumbal Xray AP Lateral
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Chronic Kidney Disease• An : History of Diabetic Mellitus since 5 years ago,
Hypertension since 5 years ago, Urinate rarely , swollen leg• PE : Conjungtiva anemis, Asetonic smell, Pitting edema• Lab : decrease Red Blood cel component, Increase Ureum
and creatinin level
• Planning : blood gass analysis, Albumin
• Th : Hemodialisa
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3. HypertensionAn : history of Hypertension and drug history of Amlodipine 2x5mgPE : BP : 150/70 mmHgTh: Amlodipine 5 mg
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• Diabetic MellitusAn : History of DM since 5 yearsLab : GDP 245 mg /dlTh: Glurenorem
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Burn Sensation in abdominal
• Clinical manifestation physical laboratory :- Burn sensation examination - hb : 9.9 g/dl - Pain - pale conjungtiva - leukocyte : 13.030 • Severity - aceton smell (+) - urea : 154- Clinical manifestation - CDL on regio coli - creatinin : 10.6- Swollen leg - pretibial pitting edema - blood gluccose 245• Commorbid disease - DM urinalisis - Hipertension - protein : ++• Past history - blood +++- DM - gluccose : +- Hipertension - ECG• Social history - chest x ray- Smoking 1 pack a day for 50 years(brinkman index = severe)
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How Diabetes Mellitus affects the renal function
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