KASUS PEMBELAJARAN KLINIK

PERTEMUAN KE 2

1. Gagal ginjal akut

DATA PASIEN

Pasien S, laki-laki, 49 th
Masuk RS via IGD pada Tgl.15-04-2012 jam 17:01:59

IGD
Keadaan Umum: buruk
Keluhan utama: lemas ± 2 hari, mual (+), sulit diajak komunikasi, BAK sedikit, mata: anemis (+).
GDS: 197 mg/dL.
Diagnosa utama: CRF
Diagnosa banding: ARF
Diagnosa Komorbid: susp.Leptospirosis
Suhu: 36°C, Tekanan darah: 160/80 mmHg, Pernapasan: 20 x/menit.

RAWAT INAP
Anamnesa:
± 2 hari lemas, mual (+), sulit diajak komunikasi.
Pemeriksaan:
Tanda vital: suhu: 36°C, TD: 160/80 mmHg, RR: 20x/menit.
Pemeriksaan fisik: KU lemah apatis
Mata: anemis (+)
THT: napas cuping (-)
Thorax: C bising (-), P: sp ves
Abdomen: supel, bising usus (+) N
Ekstrimitas: akral dingin
Diagnosa Kerja: Observasi CRF
Diagnosa Banding: ARF, Leptospirosis
Hasil Pemeriksaan EKG: sinus bradikardia
Laju Filtrasi Glomerulus (LFG) = 8,91
DATA LABORATORIUM

PARAMETER SATUAN 14-04-2012 15-04-2012 16-04-2012

Hemoglobin g/dL 9 12,4 11,1

Eritrosit /μL 279.000 331.000 377.000
Leukosit /μL 32.000 29.900 27.900
Trombosit /μL 333.000 321.000 292.000
Hematokrit % 24 29,6 33,7
Limfosit # /μL - 9.200 8.600
Monosit # /μL - 1.000 1.600
Granulosit # /μL - 19.700 17.700
Limfosit % % - 30,7 30,7
Monosit % % - 3,3 5,7
Granulosit % % - 66,0 63,5
MCV Fl - 89,4 89,3
MCH Bg - 37,4 29,4
MCHC g/dL - 41,8 32,9
RDW % - 15,3 14,9
PCT % - 0,272 0,233
MPV Fl - 8,5 8
PDW Fl - 11,0 12,6
GDS mg/dL 345 197 -
Ureum mg/dL 241 151 -
Kreatinin mg/dL 6,1 7,09 -
SGOT mg/dL 33 - -
SGPT mg/dL 7 - -
Asam urat mg/dL 4,4 - -
Bilirubin direk mg/dL 0,4 - -
Bilirubin indirek mg/dL 0,2 - -
Bilirubin total mg/dL 0,6 - -
Kolesterol mg/dL 330 - -
Trigliserida mg/dL 171 - -
Natrium mmol/L - 122,3 -
Kalium mmol/L - 7,14 -
Kalsium mmol/L - 1,12 -
HBsAg - (-) - -
Plasmodium - - (-) -
falciparum
Plasmodium lain - - (-) -
(vivax,ovale,malariae)

DATA KLINIS

PARAMETER SATUAN NILAI 14-04-2012 15-04-2012 16-04-2012

NORMAL

Suhu °C 36 - 36 37,8
Tekanan Darah mmHg 110/80 - 160/80 160/90
Pernapasan kali/menit 20 – 24 - 20 -
Pertanyaan :

1. Sebutkan tanda-tanda yang menunjukkan terjadi penyakit GGA pada kasus diatas!
2. Kasus diatas termasuk GGA jenis apa?
3. Bagaimana tatalaksana terapi yang tepat untuk kasus diatas?
4. Bagaimana monitoringnya?

2. Gagal ginjal kronis

Pasien G.A. 23 tahun masuk RS dengan keluhan sesak nafas sejak tadi malam,batuk (+),
lemah dan didiagnosa menderita CKD+anemia+hipertensi. Pasien sudah menderita CKD
sejak 2009. Pasien sering mengkonsumsi minuman suplemen.
Terapi :

Obat Rute Dosis Frek

O2 nasal 4 l/menit

D5 iv 12tts/mnt

Aminoleban iv 1 kolf/hri

Aminepron po 3x2

Starquin
iv 200 mg 2x200 mg
(Ciprofloksasin)

Cefadroxil po 500 mg 2x500 mg

Ranitidine iv 50mg 2x1 ampul

Lasix (Furosemide) iv 20mg 3x1 ampul

1-0-0
Adalatoros
po 30 mg
(Nifedipin) 2-0-0

ISDN po 10 mg 3x1

Valsartan po 80 mg 2-0-0
Concor
po 2,5 mg 2-0-0
(Bisoprololfumarat)

Hytrin (Terazosin) po 2 mg 1-0-0

Neurodex po 3x1 tab

Neurobion 5000 iv 1x1 ampul

Ponstan po 500mg prn

Codein po 10 mg prn

PRC 1 kolf

Tanggal (Bulan Mei)

DATA
KLINIK
(Yang penting)
3 4 5 6 7 8 9 10 11 12 13 14

Tekanandarah 190/ 160/ 180/ 160/ 140/ 160/ 170/ 190 190/ 200 180 160/
(120/80 120 90 120 110 90 100 120 / 120 /12 /12 120
mmHg) 120 0 0

Nadi 84 84 84 80 84 80 96 86 84 88 88 84
(80-100x/mnt)

RR 20 20 20 20 20 20 20 20 20 20 20 20
(20-24x/mnt)

Suhu 37 36 36 36 36 36 36 36 36 38 37 36
(36,5-37,5o C)

UT (ml) 400 500 600

Sesak + + +

Batuk + + + +

Lemah + + + + + + + + + + + +

Parameter Kadar 3/5 4/5 4/5 5/5 7/5 7/ 11/5 11/5 11/5 12/5
normal (post 5 pre post
op)

Hemoglobin 13,5-18 6,2 6,2 10,1 7,6 10,5

g/dl
Leukosit 4000-10000 5600 7100 6500 7400
3
/mm

Trombosit (15-45).104 87000 93000 95000 97000

3
/ mm

Hematokrit 40-54 % 16,5 25,9 20,5 27,1

GDA 70-110 287 85 61

mg/dl

Asam urat 3,4 – 7,0 8,5 5,5

mg/dl

GDP 60-110 71
mg/dl

GD2PP <125 82
mg/dL

Albumin 3,5-5,2 g/dl 3,6 3,6

Globulin 1,5-3,5 g/dl 3,0

BUN 8-20 mg/dl 66,1 33,4 109 5 120,9 115,3 57,0

,9 9,
4

Kreatinin 0,6-1,2 18,07 10,82 19, 1 19,63 9,38 10,58

mg/dl 6 1,
1

Na 135-145 127 125

meq/l

K 3,6-5,5 5,3 7,0

mmol/l

Cl 97-103 93 95
mmol/L

pH 7,35 – 7,45 7,505 7,508

pCO2 35 – 45 30,2 32,8

mmHg

pO2 80 – 100 60 74
mmHg

3. R.T. is a 60-year-old HD patient who has had ESRD for 10 years. His HD access is a left rteriovenous
fistula. He has a history of hypertension, CAD, mild CHF, type 2 diabetes mellitus, and a seizure disorder.
Medications: Epoetin 14,000 units 3 times/week at dialysis; multivitamin (Nephrocaps) once daily;
atorvastatin 20 mg/day; insulin; calcium acetate 2 tablets 3 times/day with meals; phenytoin 300 mg/day;
 and intravenous iron 100 mg/month. Laboratory values: Hemoglobin 10.2 g/dL; immunoassay for PTH
(iPTH) 800 pcg/mL; Na 140 mEq/L; K 4.9 mEq/L; Cr 7.0 mg/dL; calcium 9 mg/dL; albumin 2.5 g/dL; and
phosphorus 7.8 mg/dL. Serum ferritin is 200 ng/mL, and transferrin saturation is 32%. The RBC indices are
normal. His WBC is normal. He is afebrile. What a most likely contributing to relative epoetin resistance in
this patient? In addition to diet modification and emphasizing adherence, what the best approach to
managing this patient’s hyperparathyroidism and renal osteodystrophy?

4. A.M. is a 75-year-old man who presents to your institution with abdominal pain and dizziness. He has a brief
history of gastroenteritis and has had nothing to eat or drink for 24 hours. His blood pressure (BP) reading
while sitting is 120/80 mm Hg, which drops to 90/60 mm Hg when standing. His heart rate is 90
beats/minute. His basic metabolic panel shows sodium (Na) 135 mEq/L; chloride (Cl) 108 mEq/L;
potassium (K) 4.7 mEq/L; CO 2 26 mEq/L; blood urea nitrogen (BUN) 40 mg/dL; serum creatinine (SCr) 1.5
mg/dL; and glucose 188 mg/dL. He has no known drug allergies. His weight is 92.5 kg, and his height is
6′1′′. What the best approach to treat this patient?

5. M.M.R., a 59-year-old patient who has had endstage renal disease (ESRD) for 10 years, is maintained on
chronic hemodialysis (HD). He has a history of hypertension, coronary artery disease (CAD), mild
congestive heart failure (CHF), and type 2 diabetes mellitus. Medications are as follows: epoetin 10,000
units intravenously 3 times/ week at dialysis; Nephrocaps once daily; atorvastatin 20 mg/day; insulin; and
calcium acetate 2 tablets 3 times/day with meals. Laboratory values are as follows: hemoglobin 9.2 g/dL,
parathyroid hormone (PTH) 300 pg/mL, Na 140 mEq/L, K 4.9 mEq/L, Cr 7.0 mg/dL, calcium 9 mg/dL,
albumin 3.5 g/L, and phosphorus 4.8 mg/dL. He has a serum ferritin concentration of 80 ng/mL and a
transferrin saturation of 14%. The red blood cell count (RBC) indices (mean corpuscular volume, mean
corpuscular hemoglobin count) are normal. His white blood cell count (WBC) is normal. He is afebrile.
What the best approach to managing anemia in this patient?