Case Dr Arief

7/28/2019 Case Dr Arief

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Chronic Kidney Disease e.c Nephrotic

Syndrome

By:DINI NOVIANI PRATIWIO3008084


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ANAMNESE

Autoanamnese on 28th

of June2012 at 13.00


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Mrs. EncumName

51 years oldAge

femaleSex

Jogol 04- KarawangAddress

Elementary schoolEducation

HousewifeOccupation

IslamReligion

MarriedMarital status

June 26 th 2012Admitted

JatisariTaken from


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HISTORY TAKING

CHIEFCOMPLAINT

Swelling of face, abdomen

and legs since 3 month

ADDITIONALCOMPLAINT

Pain on the waist

Slightly short of breath

Headache

Pain on urinationNause


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HISTORY OF PRESENT ILLNESS

A patient came to Emergency Unit RSUD Karawang with a complaint of

swelling of face, abdomen and legs since 3 month before admission. The

symptom appeared first on the face then goes to the stomach and legs. The

swelling of the eyelid begins especially in the morning. When the swelling get

worsen, shes having slight short of breath. This shortness of breath is notaffected by cold, dust, or emotion, and no wheezing. She denied of having a

fever, no vomitting but suffered a bit of headache which occur once at times

and nausea

She also complained of having pain on her waist three month beforeshe was admitted and feeling pain during urination, the colour of the urine is

dark yellow with slightly dusk and foamy but the frequency is not decreased and

have no blood appearance. Defecation is normal. She also complained she had

lost weight since one year ago from 75 kg to 60 kg.


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Picture


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HISTORY OF PAST ILLNESS

HYPERTENSION

( + )

DIABETES

( - )

KIDNEY DISEASE

( - )

ASTHMA

( - )


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FAMILY HISTORY

No one in herfamily got

disease likehers

Diabetesmellitus -

Hypertension-

Asthma -


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MEDICATION HISTORY

The patient has never beenadmitted to hospital before

Not to consume certain drugs only

taking panadol just to get rid of the

headache


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PERSONAL AND SOCIAL HISTORY

Noconsumptionof herbal

drink

No smoke,no

consumptionof alcohol or

drugs

Seldomexercise
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General condition

General appearance moderately ill

conciousness

Compos mentis

Height

165 cm

Weight

60 kg

BMI NORMAL

22,2kg/m2


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VITAL SIGN

BLOODPRESSURE

: 180/100

TEMP : 36,8C

HEART

RATE :64x/mn

RESP RATE: 20x/mn


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PHYSICAL EXAMINATION

NORMOCEPHALY

HEAD

ANEMIC CONJUCTIVA +/+

ICTERIC SCLERA -/-

PERIORBITAL ODEMA +/+

EYES

LYMPYH NODE IS NOT PALPABLE THYROID GLAND IS NOT PALPABLE

JVP 5+2 cmH2O

NECK

Lip cyanosis(-) pallor (-)

Pharynx hyperemic (-), symmetrical, uvula midline

MOUTH


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THORAX

INSPECTION

Ictus Cordis is visible

ICS LMCSPALPATION

Ictus cordis is palpable at 5th ICS LMCS

PERCUTION

Right heart border: ICS III-V LSD

Left heart border: ICS V 1cm medial LMCS

Upper heart border: ICS III LPSS

AUSCULTATION

Regular I II Heart Sound,

Murmur (-), Gallop (-)


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Lung Examination

THORAX

Inspection :Symmetrical

Supraclavicula retraction(-)

Intercostalis retraction(-) Palpation :Equal vocal fremitus

Percussion :Sonor in both lung

Auscultation :Vesicular breath sound in both lung

Wh -/-, Rh -/-


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Abdominal Examination

InspectionBrown skin, distended abdomen

Palpation

No Pain on palpation at Epigastric Liver not palpableSpleen not palpable

PercussionNo pain present on abdominal percussion

Sound DullnessShifting dullness (+)CVA (-)

AuscultationBowel sound (+) 2 times/minute. Arterial bruit (-), venous hum

(-)


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Extremity ExaminationExtremity examination

WARM ACRALS

OEDEM

+ +

+ +

- -

+ +


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Laboratory findings

Test Result Normal values

Hb 7,1 (12 17) g%

HT 28 (37 48) %

Trombocyte 104.000 (150.000 450.000) /ul

Leukocyte 4100 (5000 10000) /ul

Blood sugar 140 70 140 mg/dl

Ureum 68,7 10 45 mg %

Creatinin 1,60 0,4 1,5 mg%

Total Protein 4,57 6.1- 8,2 gr&

Albumin 1,91 3,5 5,0 mg%

Globulin 2,4 2,6 3,6 mg%

Blood :29th June 2012


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Laboratory findings

TESTS RESULT NORMAL

Colour and

turbidity

Yellow, turbid

pH 6,5 4,5-8,0

Protein + 2 -

Epitel +1 1

Leukosyte 3-5/LPB 0 5 / LPB

Eritrosit 1-2/LPB 0 5 / LPB

Urinalysis :

29th June 2012


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Laboratory findings

Test Result Normal

Cholesterol 210


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Resume

HistoryTakingSwelling of

face, abdomen& legs 3 monthbeforehospitalized.

Slight short ofbreath.

Headache.

Pain onurination.

Pain on waist.Nausea Ph

ysicalExa

mination

Periorbitaloedema +/+

Anemicconjungtiva +/+

Shifting dullness(+)

oedema of legs+/+.

AdjuvantTest

Hb : 7,1 g %.

Ht : 28 %.

Albumin : 1,91 mg

%.Globulin : 2,4 mg %

Cholesterol : 210mg/dl

Ureum: 68,7 mg%

Creatinin :1,60 mg%GFR : 39,4

Urinalysis : turbid,protein +2


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MALNUTRITION

ACUTEGLOMERULONEPHRITIS

CONGESTIVE HEARTFAILURE

DIFFERENTIAL DIAGNOSIS


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WORKING DIAGNOSIS

3rd grade of Chronic

Kidney Disease e.c

Nephrotic Syndrome


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RenalBoipsy

ECG

RontgenThorax

SUGGESTED

EXAMINATION


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THERAPY

Consumption of 0.8

grams protein / kg / day

Diets low in SALT

bed rest

IVFD D 5% 8 dpm.

Transfusi PRC 3 kolf

Lasix 2 x 1amp.

Caco3, as folat 3x1 tab

Methylprednisolon

3x62,5mg.

Ranitidin 2 x 1 amp.

Symvastatine 1x 10mg.

Captopril 3 x 6,25 mg.

Albumin 20% 1x1.

Ketorolac 3x1 amp


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prognosis

Adsanationam

dubia admalam

AdFungsionam

dubia ad

malam

Ad Vitam

Dubia adbonam


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