Patient information: the patient, Mr. S was 50 years old, lived in Tambak Asri, was married, self-employed, with high school education, Javanese, Muslim. He had been treated at the Dr. Soetomo Hospital on November 21, 2018. The patient presented to the hospital complaining of a swelling on the right leg which occurred 5 days before hospital admission. The swelling had become more prominent over time and was accompanied by pain in the right leg which occurred 2 days before admission. Pain affected the entire right leg, and was intermittent. In addition, the patient also complained of intermittent shortness of breath which occurred one month before. However, the patient did not have shortness of breath when he was admitted to the hospital. Fever, cough, weight loss, decreased appetite, and night sweats were not reported. The amount of urine produced in a day was 200-300 ml and no defecation problem was reported. The patient had a history of pulmonary tuberculosis (TB) successfully treated in 2015.
Clinical findings: the patient had a history of hospitalization at the Dr. Soetomo Hospital 1 week before due to chronic kidney disease (CKD) stage V + refractory hyperkalemia + left solitary kidney + left kidney stone + left ureteral stone + bladder stone + community acquired pneumonia (CAP) + stage II hypertension + obstruction syndrome post TB. He had undergone lumen catheter insertion in the right femoral vein (previous treatment) and removed when re-hospitalized. He underwent hemodialysis during the previous treatment (10th November 2018). A family history of diabetes, hypertension, heart disease, liver, and kidney disease was not reported. During the previous treatment, the patient was scheduled for vesicolithotripsy+ ureteroscopy (URS), but the patient refused it.
On physical examination, he was compos mentis, blood pressure was 100/70 mmHg, pulse rate was 98 beats per minute, respiration rate 24 breaths per minute, body temperature 36.9 C, SpO296% (free air), body mass index (BMI) 22.9 kg/m2 and Wong-Baker pain scale was 3. He had pebral conjunctiva (-/-), icterus (-), cyanosis (-), dyspnea (-); single S1S2, murmur (-), gallop (-); inspection (left lung), increased palpation in the right upper lung, dullness in the right upper lung, vesicular/vesicular breath sound, rhonchi (-/-), wheezing (+) in the right lower lung. There were soepel, normal bowel sounds on abdominal examination, liver and spleen were not palpable, shifting dullness (-), muscular defense (-). On examination of the right lower extremity, there was edema (+), redness (+), it was warm (+), and Wells' score was 3.
Supporting examination results showed that haemoglobin was 11.4 g/dl, erythrocytes were 4.01 x 106/ul, leukocytes 27.99 x 103/ul, platelets 317 x 103/ul, BUN 60 mg/dl, serum creatinine was 9.93 mg/dl, albumin 3.27 gram/dl, random blood glucose 125 mg/dl, sodium 136 mmol/L, potassium 6 mmol/l, chloride 95 mmol/l, HbSAg rapid test is (-), serum glutamic-oxaloacetic transaminase (SGOT) 28 U/l, SGPT 34 U/l, PPT 10.0 seconds, activated activated partial thromboplastin time (APTT) 30.5 seconds. Urinalysis: glucose (-), ketones (-), bilirubin (-), SG 1.005, blood +4, pH 7, protein (-), urobilinogen (-), nitrite (-), leukocytes +3, erythrocytes 25-50/lp, leukocytes 15-20/hpf. Blood gas analysis: pH 7.32, pCO245 mmHg, pO267.2 mmHg, HCO320 mmol/L, BEecf -4.4 mmol/L, oxygen saturation (SO2) 96%. Sputum examination on November 3, 2018 did not revealed any acid resistant bacteria, and electrocardiography (ECG) examination detected sinus tachycardia. Radiological examinations were based on: 1) Anteroposterior (AP) chest X-ray which showed upper lobe atelectasis and right lung fibrosis, pulmonary TB sequelae, right pleural effusion, and no abnormalities were seen; 2) AP/lateral pedis and cruris right position photo with no abnormal results; 3) AP and lateral radiographs of the right femur showed no abnormality, ultrasound objectified solitary kidney on the left, mild hydronephrosis and left hydroureter which could be caused by left renal pelvis stones, bladder stones; 4) multislice computed tomography (MSCT) stonography showed left solitary kidney, left renal pelvis stone and left medial 1/3 stone causing left 1/3 proximal hydroureter and left mild hydronephrosis, bladder stone.
Second day of treatment: complaints of swelling with intermittent right leg pain, shortness of breath (-). Physical examination: compost mentis, blood pressure 110/70 mmHg, pulse rate 98 beats per minute, respiration rate 24 breaths per minute, temperature 36.7 C, SpO298% free air, urine production 650 ml/24 hours (drinking 600 ml + correction fluid 60 ml), lower extremity dextraedema (+), redness (+), and warm (+). Laboratory tests: BUN 52 mg/dl, serum creatinine 7.01 mg/dl, sodium 132 mmol/l, potassium 6.8 mmol/l, chloride 91 mmol/l. Assessment: acute on CKD + sepsis et cause urinary tract infection (UTI) + suspected DVT in the right lower extremity associated with differential leucocyte count (DLC) + hyperkalemia (6.8 mmol/l) + left mild hydronephrosis with medial 1/3 left hydroureter et causa left renal stone and ureteral stone + bladder stones + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Therapy planning: three-step treatment of hyperkalemia (ca gluconate 1 ampoule IV injection followed by D40 + 2 units of insulin as part every 30 minutes for 3 times), nebulization of salbutamol 2.5 mg + ipratropium bromide every 8 hours, fluid restriction (maximum drink of 600 ml), other therapy remains. Planning diagnosis: complete blood count (CBC) evaluation, potassium serum post-correction (5.2 mmol/l), serial renal function test (RFT), and D-dimer. Monitoring included: clinical examination, vital signs, and urine production.
Third-day of treatment: complaints of swelling with intermittent right leg pain, shortness of breath (-). Physical examination: compost mentis, blood pressure 110/70 mmHg, pulse rate 93 beats per minute, respiration rate 20 breaths per minute, temperature 36.7 C, SpO298% free air, urine production 1000 ml/24 hours (drinking 600 ml + correction fluid 85 ml), right lower extremity edema (+), redness (+), and warm (+). Laboratory tests: BUN 50 mg/dl, serum creatinine 6.89 mg/dl, sodium 135 mmol/l, potassium 6.2 mmol/l, and chloride 87 mmol/l. Assessment: acute on CKD + sepsis et causa UTI + suspected DVT in the right lower extremity associated with DLC + hyperkalemia (6.2 mmol/l) + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stones + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Therapy planning: two-step treatment of hyperkalemia (ca gluconate 1 ampoule iv injection followed by D40 + 2 units of insulin as part every 30 minutes for 2 times), IVFD D5 + 10 units of insulin as part 7 drops per minute, fluid restriction (drinking a maximum of 1000 ml), other therapies. Planning diagnosis: CBC evaluation, potassium serum post correction (5.0 mmol/l), serial RFT, and D-dimer. Monitoring: clinical examination, vital signs, and urine production.
Fourth-day of treatment: complaints: swelling accompanied by intermittent pain in the right leg, shortness of breath (-). Physical examination: compost mentis, blood pressure 120/90 mmHg, pulse rate 96 beats per minute, respiration rate 20 breaths per minute, temperature 36.1 C, SpO298% free air, urine production 1400 ml/24 hours (drink 1000 ml + infusion 500 ml + 60 ml correction fluid), lower extremity dextraedema (+), redness (+), and warm (+). Laboratory tests showed hemoglobin 10.4 g/dl, erythrocytes 4.12 x 106/ul, leukocytes 23.25 x 103/ul, platelets 378 x103/ul, BUN 44 mg/dl, serum creatinine 6.51 mg/dl, sodium 135 mmol/l, potassium 4.8 mmol/l, chloride 95 mmol/l, D-dimer >4 g/ml (normal <0.5 microg/ml). Assessment: acute on CKD + sepsis et cause UTI + suspected DVT right lower extremity associated with DLC + corrected hyperkalemia (4.8) + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae.
Diagnosis: complete blood count, serial RFT, Doppler ultrasound of the right lower extremity (scheduled in 28th November 2018), and vascular duplex ultrasound scanning (DUS) echo (scheduled in 30th November 2018). Therapy planning and monitoring were the same.
Sixth-day of treatment: complaints of swelling accompanied by intermittent pain in the right leg, and shortness of breath (-). On physical examination, the patient was compost mentis, blood pressure 130/90 mmHg, pulse rate 98 beats per minute, respiration rate 20 breaths per minute, temperature 36.2 C, SpO297% free air, urine production 1500 ml/24 hours (infusion 500 ml + 1000 ml drink), lower extremity dextraedema (+), redness (+), and warm (+). Assessment, diagnosis, therapy, and monitoring were the same.
Seventh-day of treatment: complaints of swelling accompanied by intermittent pain in the right leg. Physical examination, the patient was compost mentis, blood pressure 130/90 mmHg, pulse rate 97 beats per minute, respiration rate 20 breaths per minute, temperature 36.7 C, SpO299% free air, urine production 2000 ml/24 hours (infusion 500 ml + 1500 ml drink), right lower extremity edema (+), redness (+), and warm (+). Laboratory tests showed hemoglobin 11.3 g/dl, erythrocytes 4.48 x 106/ul, leukocytes 15.38 x 103/ul, platelets 375 x 103/ul, BUN 20 mg/dl, serum creatinine 1.52 mg/dl, sodium 137 mmol/l, potassium 4.8 mmol/l, and chloride 91 mmol/l. Assessment: acute on CKD + sepsis et cause UTI + suspected DVT in the right lower extremity associated with DLC + corrected hyperkalemia (4.8) + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Diagnosis, therapy, and monitoring were the same.
Eigth-day of treatment: complaints of swelling accompanied by intermittent pain in the right leg. On physical examination, the patient was compost mentis, blood pressure 130/80 mmHg, pulse rate 89 beats per minute, respiration rate 20 breaths per minute, temperature 37.0 C, SpO299% free air, urine production 2000 ml/24 hours (infusion 500 ml + 1500 ml drink), right lower extremity edema (+), redness (+), and warm (+). Assessment: acute on CKD + sepsis et causa UTI + DVT in the right lower limb associated with DLC + corrected hyperkalemia (4.8) + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Diagnosis: Doppler ultrasound of right lower extremity (today), while others were the same. Therapy: venflon, other therapies were same. Monitoring was constant.
Ninth-day of treatment: complaints of swelling accompanied by intermittent pain in the right leg. On physical examination, the patient was compost mentis, blood pressure 130/80 mmHg, pulse rate 89 beats per minute, respiration rate 20 breaths per minute, temperature 36.7 C, SpO298% free air, urine production 1500 ml/24 hours (drinking of 1500 ml), lower extremity dextraedema (+), redness (+), and warm (+). Patient assessment: acute on CKD + sepsis and cause UTI + suspected deep vein thrombosis (DVT) in the right lower extremity associated with DLC + corrected hyperkalemia (4.8) + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Diagnosis: waiting for result of Doppler ultrasound of the right lower extremity. Therapy and monitoring were the same.
Tenth-day of treatment: complaints of swelling accompanied by intermittent pain in the right leg. Physical examination: compost mentis, blood pressure 130/80 mmHg, pulse rate 89 beats per minute, respiration rate 20 breaths per minute, temperature 36.8 C, SpO298% free air, urine production 1200 ml/24 hours (drinking 1200 ml), lower extremity dextraedema (+), redness (+), and warm (+). Laboratory tests showed hemoglobin 10.3 g/dl, hematocrit 32.8%, erythrocytes 3.65 x 106/ul, leukocytes 10.23 x 103/ul, platelets 168 x 103/ul, BUN 12 mg/ul. Dl, serum creatinine 0.89 mg/dl, sodium 133 mmol/l, potassium 3.6 mmol/l, chloride 99 mmol/l. Patient assessment: acute on CKD + post sepsis + suspected deep vein thrombosis (DVT) in the right lower extremity associated with DLC + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Planning diagnosis: waiting for the right lower extremity Doppler ultrasound results, vascular DUS echo (today), others tests were the same. Therapy planning and constant monitoring were the same.
Thirteenth day of treatment: complaints of swelling accompanied by intermittent pain in the right leg. Physical examination: compost mentis, blood pressure 130/80 mmHg, pulse rate 90 beats per minute, respiration rate 20 breaths per minute, temperature 36.7 C, urine production 1200 ml/24 hours (drinking 1200 ml/24 hours), lower extremities dextraedema (+), redness (+), and warm (+). Doppler ultrasound of the right lower extremity showed: 1) Diffuse deep vein thrombosis from the common femoral vein, great saphenous vein (GSV), common femoral, superficial, popliteal vein, into right distal posterior tibial vein with subcutaneous edema at the level of the femoral artery to the right dorsalis pedis; 2) no stenosis/occlusion/vascular malformation of the arterial system was seen. Vascular ultrasound (DUS) showed deep vein thrombosis in the right lower extremity. Laboratory results: INR 0.93. Assessment: acute on CKD + post sepsis + deep vein thrombosis (DVT) in the right lower extremity associated with DLC + left mild hydronephrosis with medial 1/3 left hydroureter and cause left renal stone and ureteral stone + bladder stone + left solitary kidney + controlled hypertension + pulmonary tuberculosis sequelae. Planning diagnosis: INR evaluation. Treatment: fondaparinux injection 7.5 mg every 24 hours im (first day).
Fourteenth day of treatment: complaints: swelling accompanied by intermittent pain in the right leg. Physical examination showed compos mentis, blood pressure 130/80 mmHg, pulse rate 92 beats per minute, respiration rate 20 breaths per minute, temperature 36.0 C, urine production 1200 ml/24 hours (1200 ml drinking), lower extremity dextraedema (+), redness (+), and warm (+). The assessment was the same. Diagnosis: INR evaluation. Therapy: fondaparinux 7.5 mg injection for 24 hours (second day), the other therapy was the same.
Fifteenth day of treatment: complaints: reduced swelling with pain in the right leg. Physical examination showed compos mentis, blood pressure 130/80 mmHg, pulse rate 90 beats per minute, respiration rate 20 breaths per minute, temperature 36.7 C, urine production 1200 ml/24 hours (1200 ml drinking), reduced lower extremity dextraedema. The assessment was the same. Diagnosis: INR evaluation. Therapy: fondaparinux 7.5 mg injection in 24 hours im (third day), warfarin 2 mg/24 hours (first day), the other therapy was the same.
Sixteenth day of treatment: complaints: reduced swelling and pain in the right leg. Physical examination showed compos mentis, blood pressure 130/80 mmHg, pulse rate 90 beats per minute, respiration rate 20 breaths per minute, temperature 37.2 C, urine production 1500 ml/24 hours (drinking 1500 ml), reduced dextra edema in lower extremities. Laboratory test results: INR 1. Diagnosis: INR evaluation. Therapy: fondaparinux injection 7.5 mg/24 hours im (fourth day), warfarin 2 mg/24 hours (second day), other therapy.
Eighteenth day of treatment: complaints: swelling and pain in the right leg is reduced. Physical examination showed compos mentis, blood pressure 130/80 mmHg, pulse rate 92 beats per minute, respiration rate 20 breaths per minute, temperature 37.0 C, reduced dextra lower extremity edema. Laboratory: INR evaluation. Patient assessments were the same. Diagnosis: RFT evaluation, INR evaluation. Treatment: fondaparinux injection 7.5 mg/24 hours im (sixth day), warfarin 2 mg/24 hours (fourth day), other therapy.
Twenty-first day of treatment: complaints: swelling and pain in the right leg is reduced. Physical examination showed compos mentis, blood pressure 130/80 mmHg, and rate of 92 beats per minute, respiration rate of 20 breaths per minute, temperature 37.0 C, reduced dextraedema in lower extremities. Laboratory: INR 2.5. The patient assessment was the same. Diagnosis: none. Therapy: injection of fondaparinux 7.5 mg/24 hours im (stop), warfarin 2 mg/24 hours (seventh day), other therapy.
Diagnostic assessment: assessment: atelectasis, right pulmonary fibrosis, TB sequelae and right pleural effusion. There were no signs of active pulmonary tuberculosis on clinical, radiological, and microscopic assessment. Diagnosis: spirometry when the patient was stable. Treatment planning: O2nasal cannula 3-4 liters per minute (lpm) prn, nebulized salbutamol 2.5 mg + ipratropium bromide every 8 hours. Thoracic-cardiovascular surgery consultation: Doppler ultrasound of the right lower extremity and elastic bandage. Heart consultation: DVT in the right lower extremity has not been ruled out. Diagnosis: echo vascular duplex ultrasound (DUS). Treatment: right lower extremity compression splinting.
Diagnosis: initial assessment showed acute CKD + sepsis et cause UTI + suspected deep vein thrombosis (DVT) in the right lower limb associated with DLC + hyperkalemia (6.0 mmol/l) + left mild hydronephrosis with left medial 1/3 hydroureter and cause left renal stone and ureteral stone + bladder stones + left solitary kidneys + controlled hypertension + pulmonary tuberculosis sequelae. Initial therapy planning included high-calorie diet (2100 calories per day) low in protein and salt, no fruit, vegetables, broth; venflon/syringe only, 2-step treatment of hyperkalemia (ca gluconate 1 ampoule iv injection, followed by D40 + 2 units of insulin as part twice every 30 minutes), injection of ceftriaxone 1 gram every 12 hours iv, injection of ranitidine 50 mg every 24 hours iv, paracetamol 500 mg every 8 hours prn, amlodipine 10 mg every 24 hours, and fluid restriction (drink maximum 600 ml/24 hours). Diagnosis was based on complete blood count, repeated RFT l, post-corrected serum potassium (5.3 mmol/l), blood culture, urine culture, and D-dimer. Monitoring was based on clinical examination, vital signs, and urine production.
Informed consent: the informed consent is provided by the Dr. Soetomo Hospital and given to the patient. The patient agreed to the informed consent on November 21, 2018 at 12.00 pm for examination in Pandan I Room, Class III.