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

Patient’s Identity

• Name : Tn. T• Age : 69 y.o• Address : Jalan Kayu Manis Baru Jaktim• Job : Army• Married

Anamnesis

• Chief Complaint :Burning sensation and pain in abdominal since

one day before hospital

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

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

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

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)

• 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 (-)

• 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 (-)

• 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

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

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

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

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

• 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

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

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

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

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

3. HypertensionAn : history of Hypertension and drug history of Amlodipine 2x5mgPE : BP : 150/70 mmHgTh: Amlodipine 5 mg

• Diabetic MellitusAn : History of DM since 5 yearsLab : GDP 245 mg /dlTh: Glurenorem

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)

How Diabetes Mellitus affects the renal function