Commorbid Diseases involve metabolic disorders and abnormality of mucosal system. Diabetes Mellitus as the main problem of the diseases

1. Duty Report
Chronic Kidney Diseases, DM
and GERD :
Approach of complexity problem
Supervisor : Dr .dr. Soroy Lardo, Sp.PD FINASIM
Irnanita Pratiwi
Maharani Falerisya N
Division Infectious Diseases and Tropical Medicine
Department of Internal Medicine
Indonesian Army Central Hospital Gatot Soebroto
Faculty of Medicine UPN Veteran Jakarta

2. Patient’s Identity
• Name : Tn. T
• Age : 69 y.o
• Address : Jalan Kayu Manis Baru
Jaktim
• Job : Army
• Married

3. Anamnesis
• Chief Complaint :
Burning sensation and pain in abdominal since
one day before hospital

4. 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

5. 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

6. TREATMENT HISTORY
• Amlodipine 1 x 5 mg
• Glurenorm 30 mg
FAMILY 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

7. Physical Examination
• General state : moderate illness
• Consiousness : Compos Mentis
• Vital Sign
Blood Pressure : 150/70 mmHg
Pulse : 80 x /minute, regular
Temperature : 37,0oC
Respiration Rate : 18x/minute
Body Weight : 77 kg
Body Height : 172 cm
BMI : 26 (Obesse I, Asian – Pacific perspective)

8. • 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 space
Palpation : symmetric tactile fremitus, symmetric chest expansion
Percussion : Resonant sound bilateraly (sonor)
Auscultation : Vesicular breathing sound bilaterally (+), Rhonki (-),
Wheezing (-)

9. • Heart :
Inspection : No visible ictus cordis
Palpation : Ictus cordis at ICS 5 linea midclavicula
sinistra
Percussion :
-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 (-)

10. • Abdomen :
Inspection : normal countour, caput medusa (-)
Auscultation : normal bowel movement
Palpation : no palpable liver and spleen,no pain when
palpating all abdomen region, normal turgor
Percussion : tympanic in all area, Shifting dullness (-)
Extremitas : warm acral, Pretibial pitting edema (+/+),
CRT <2s

11. 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 – 10.000
Diff count
Basophyle 0 0 - 1
Eosinophyle 0 1 – 3
Neutrophyle 79% ↑ 50 – 70
Limfocyte 10 % ↓ 20 - 40
Monocyte 7 % 2 - 8

12. Blood metabolic
Ureum 154 mg/dl ↑ 20 – 50
Creatinin 10,6 mg/dl ↑ 0.5 – 1.5
Glucosse 245 mg/dl ↑ 70 - 100
Electrolyte
Natrium (Na) 138 135 - 147
Kalium 3.8 3.50 – 5.00
Chloride 108.0 95.0 – 105.0

13. 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

14. 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

15. • 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

16. 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

17. 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

20. 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

22. 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

25. 3. Hypertension
An : history of Hypertension and drug history of
Amlodipine 2x5mg
PE : BP : 150/70 mmHg
Th: Amlodipine 5 mg

27. • Diabetic Mellitus
An : History of DM since 5 years
Lab : GDP 245 mg /dl
Th: Glurenorem

29. 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)

30. How Diabetes Mellitus affects the
renal function