Casse Bassed Discussion

Ega Rahmadani
30101306927

Advisor :
dr. H. M. SAUGI ABDUH, Sp.PD., KKV, FINASIM
 Patient Identity
Name : Tn. R
Age : 67 years old
Gender : Male
Religion : Moslem
Job : Entrepreneur
Address : Ds. Pomahan Rt.03 Rw 01, Kec. Sulang
Kab. Rembang
MR number : 1369920
Room : Baitussyifa 301 A
Entry date : January, 14th, 2019
Date out : Januari, 20th, 2019
Main Problem
• fatigue

History of present illness

• Patient came to the cardiac center with a
fatigue complaint since 7 days ago. Patients
felt this all day long. Patient also complained
that darkening of urine, abdominal
enlargement with pain, loss of appetite,
constipation and jaundice since 6 month ago
before coming to hospital.
 HISTORY OF ILLNESS
HISTORY OF PREVIOUS SOSIO-ECONOMIC HISTORY :
Hospital cost certified by
ILLNESS
“BPJS-NPBI”
Smoking (+)
Jaundice (+)
Hypertension history (-)
FAMILY’S HISTORY OF DISEASE
DM history (-)
Hypertension history (-)
Alergy history (-)
Alcoholic (-) DM history (-)

Heart Disease History (-)

 SISTEMIC ANAMNESIS
Chief Complains : Fatigue

Onset : 7 days ago

Location : whole body

Chronology : Patient has fatigue with enlargement and pain suddenly sin
ce 7 days ago before entered hospital.

Quality and Quantity : his symptom getting worse

Modification factor :-

Comorbid complains : darkening of urine, dysuria, constipation, abdominal enlarge

ment with pain, loss of appetite, and jaundice.
 BMI (Body Mass Indeks)
Weight : 50
High : 160
BMI = 50/(1.60 x1.60) = 19,5 Intepretation : normoweight,
weakness

General : Weakness,
Awareness : composmentis

Vital Sign
GENERAL STATUS
• Blood Pressure : 110/80 mmHg

• Heart rate : 84 x/minute

• Breath Frequency : 20 x/minute

• Temp : 36,5oC
GENERAL STATUS
Head : Mesocephal, alopesia (-)

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

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

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

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

 Mouth : fetor hepatikum (-)

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

 Extremity : palmar eritem (-), alopesia axilla (-/-)

Intepretation : icteric sclera

 LUNG EXAMINATION
INSPEKSI ANTERIOR POSTERIOR

Static RR : 20x/min, Hyper pigment (-), spider nevi RR : 20x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-), Hemithoraks D=S,
D=S, Diameter AP < LL, ginekomastia (-/-) Diameter AP < LL

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

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

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

Percution Sonor Sonor

Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
Ronchi (-)
Intepretation :
Normal
 CARDIAC EXAMINATION
Inspection : Ictus cordis isn’t 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 parasternal line
 Lower right borderline of heart : ICS V dextra sternalis line
 Lower left borderline of heart : ICS V 2 cm lateral from left mid clavicula sinis
tra
Intepretation : Normal
 ...CONT CARDIAC
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 : convex of surface, sycatric(-), striae(-), caputmedusa (-), spider nevi (-), venekta
si (-)
Auscultation : peristaltic (+), bruit hepar (+)
Percussion : redup (+) tympani (-), side of deaf (-), shifting dullness (+), undulasi (+) batas hep
ar sulit diidentiifikasi.
Palpation :
• Superfisial : tight (-), mass (-), epigastrial pain (+)
• Deep : abdominal pain in 9 region(+), liver, kidney, and spleen weren’t palpable, Murphy’
s sign (-)

Intepretation : shifting dullnes, abdominal pain, acites

EXTREMITY EXAMINATION
Ekstremitas Superior Inferior
Oedema -/- -/-
Cold +/+ +/+
Jaundice -/- -/-
Palmar eritem -/-
Alopesia axilla -/-

Intepretation : Cold of both extremity

Laboratorium Examination
 14 januari 2019

Pemeriksaan Hasil Nilai normal KIMIA

Ureum 59 (H) 10-50 mg/dl
Hemoglobin 14,8 g/dL 13,2 – 17,3
Creatinin darah 1,52 (H) 0,7-1,3 mg/dl
Hematocrit 43,6 % 33 – 45
Protein 5,60 (L) 6,0-8,0 g/dl

Leukocyte 7,96 3,6 – 10,6 ribu Albumin 2,85(L) 3,4-4,8 g/dl

Trombocyte 303 150 – 440 ribu Globulin 2,75

SGOT 943 (H) 0-50 U/i

Golongan Darah/R A/ positive
SGPT 181(H) 0-50 U/i
h

Kesan : Azotemia, hypoalbuminemia, hight sgot/sgpt

Tanggal 15/1/2019

Imunoserologi
HBsAg Kualitatif Reaktif Non Reakif
Kesan : piuria, hematu
ria, bacteriuria
Chest X-Ray

Corakan vascular tak meningkat

Tak tampak gambaran infiltrat

Cor tak membesar

USG Abdomen
15/1/2019
Kesan USG

Gambaran sirosis hepatis dengan nodul multile dilobus kanan kiri

hepar, serta masa di dilobus kanan ukuran sekitas 6,3 x 4,6 x 6,8
cm, cenderung hepatoma.
Splenomegali ringan.
Asites
Saat ini tak tampak tanda hipertensi porta.
Ginjal dan pancreas dalam batas normal.
Data Abnormal
History Taking Physical examination Additional examinatio
: n:
1. Fatigue
2. Abdominal enlargeme 8. Icteric sclera 1. Azotemia
nt 9. Convex of survac 2. Hipoalbumin
3. Abdominal pain e 3. Hight SGOT/SGP
4. Nausea 10. Abdominal pain T
5. darkening of urine 11. undulasi (+), 4. Hematuria micros
6. Constipation 12. Bruits hepar (+) copis
7. loss of appetite 13. Shifting dullnes 5. Leukosituria
8. Dysuria 6. Bacterinuria
7. HBsAg reaktif
8. USG : Asites , hep
atomegali
 PROBLEM LIST
01 03
Sirosis Hipoalbumi
Hepatis n

02 04
Azotemia Asites
 Assesment
Sirosis Chronic development of hepatitis B
Natural hystori  end stage HCC
Hepatis Stadium
• Dekompensata
Complication
 Porta Hipertention
 Encephalopati hepaticum
 Sindroma hepatorenal
 Peritonitis bacterial spontan

Initial Plan of Diagnostic

– Liver biopsy and histopatologi examination
– alfa-fetoprotein test
– PTT and APTT
– Blood Ammonia
– Anti HBsAg, IgM & IgG anti HBc, HBeAg, Anti HBeAg, HBV DNA
Sirosis
Hepatis Initial Plan of Therapy
Suportif :
1. Bed rest
2. Explain to limit consumption of drugs, especially those that are hepatot
oxic
3. Diet seimbang dengan high protein (1,2-1,5 mg/kgBB/hari)
Medikamentosa :
 Lamivudin 1 x 100 mg/hari
 Curcuma 3 x 1
Sirosis
Hepatis Initial Plan of Monitoring
1. General condition
2. Sign of bleeding
3. Hematologi
4. Biokimia serum
5. Child-Turcotte-Pugh Criteria

Initial Plan of Education

1. Explain to patients about the condition
2. Explain to limit consumption of drugs, especially those that are hepatotoxic
3. Suggest to patients to stop smoking
Acites
Assessment :
Transudat
Eksudat
IpDx :
Tes Rivalta

Ip Tx :
Non Farmakologis
Bedrest
Reduce the input of salt (sodium fluid restriction) : 5,2 gram/day
Farmakologis
Spironolacton 2 x 100 mg
Furosemid inj 2x 20 mg
Propanolol 10 mg x 2-3
Acites
Ip.Mx :
Vital sign
General condition
Input and output of fluid level (total urin 24 hours)
Albumin level
Ip. Ex :
Diet low salt
Just take food from the hospital
Consumption drug regularly
Routine control
Azotemia
Assassement : pre renal

IP Dx : USG Kidney
IP Tx :
Inhibit progreesion
Non pharmacologic :
Limitation of protein intake (0.6-0.8/kgBB/day),
Calorie Intake 30-35 kkal/kgBB/day
Control uric acid, cholesterol
Pharmacologic :
Asam folat
Kontrol tekanan darah
Retriksi asupan protein 03
Kontrol glukosa
Retriksi cairan
Retriksi garam
04
Menghindari obat – obat nefrotoksik : amino glicoside
IP Mx
Vital Sign,GFR, uremic sign, general state, awareness, fluid balance, ureum creatinin lev
el
Azotemia
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
 Laju Filtrasi Glomerulus (LFG) :
140−𝑈𝑚𝑢𝑟 𝑥𝐵𝐵 (𝑘𝑔)
= 𝑚𝑔
72𝑥𝑠𝑒𝑟𝑢𝑚 𝑘𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛( 𝑑𝐿 )

= (140- 67)x50 / 72x1,52

= 33,4 Moderat
Hypoalbuminemia
Assassemen :
etiologi : syntesis disorder
IP Dx : -

IP Tx :
Albumin correction  (3,5-2,85) X 0,8 x 46 = 23,95 gr
Albumin intake  20 % in 100 cc = 20 gr

IP Mx
Albumin status, General state, Vital Sign,

IP Ex
Explain about disease
Explain about treatment and side effect
Diit hight protein intake
 Thank you
Insert the title of your subtitle Here
AZOTEMIA
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, e
valuasi perburukan (progression) fungsi gi
njal, memperkecil risiko kardiovaskuler

2 60-89 Menghambat perburukan (progression) fun

gsi ginjal

3 30-59 Evaluasi dan terapi komplikasi

4 15-29 Persiapan untuk terapi pengganti ginjal
5 <15 Terapi pengganti ginjal
 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
50

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 a
s fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-wat
er fish, and poultry.

*(CKD Stages 1-4)

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