The document is a detailed duty report on a 69-year-old male patient presenting with abdominal pain, weakness, and leg swelling, alongside a history of diabetes and hypertension. Laboratory findings indicate significant renal impairment with elevated creatinine and urea levels, confirming chronic kidney disease, while the patient also experiences symptoms suggestive of gastroesophageal reflux disease (GERD) and potential urinary tract stones. Management strategies include hemodialysis for renal failure, dietary modifications for GERD, and treatment adjustments for hypertension and diabetes mellitus.

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