A MAN WITH SWELLING ALL OVER THE BODY

Mr. A, 50 years old presents to the Polyclinic with the complaint of swelling all over the
body since two weeks ago. The patient also complains of nausea with reduced appetite,
fatigue, and shortness of breath during activity. The patient has a history of diabetes mellitus
which was diagnosed 10 years ago. During the last 1 year, the patient complained that his
vision has been getting blurrier. Blood pressure started to rise 6 months ago.
Physical examinations: general condition looks pale, compos mentis. Height 160 cm, and
weight 73 kg. Blood pressure: 160/100 mmHg, heart rate: 104/minute, regular, respiratory
rate: 28 times/minute, deep. Temperature 36.5 0C. Conjunctiva looks pale, sclera not icteric.
JVP 5 + 3 cm H2O. Chest examination: Left heart border on 2 fingers lateral to left mid
clavicle line. The lung examination: rales at the basal lung. Abdomen examination:
hepatomegaly, blunt edges, soft, flat surface, tenderness (-), bruit (-). Ballotement (-) and
shifting dullness (+). Extremity edema (+).
Laboratory test results: Hemoglobin 8 g/dL, hematocrit 26%, leukocytes 8500/uL, platelets
180,000/uL. Ureum 80 mg/dL, creatinine 5.6 mg/dL. Sodium 140 mEq / L, Potassium 4
mEq/L, Cl 100 mEq/L. Random blood Glucose at 176 mg/dL. Complete urine: Protein (+3),
Glucose (+), Sediment: Erythrocytes 1-2 /HPF, Leukocytes 2-3 /HPF, Cylinders (-). The
patient is then treated with furosemide i.v. 20 mg every 8 hours, CaCO3 3x500 mg, Folic acid
3x1, Irbesartan 1x150 mg, Amlodipine 1x10 mg. The patient is also given PRC transfusions
targeting Hb ≥ 10 g / dL.
On the 3rd day of treatment, the patient’s conditions are improved, swelling is reduced, BP =
150/90 mmHg, heart rate 96/minute, regular, respiratory rate 20 times/minute, deep.
Temperature 36.5 0C. Shifting dullness (+), limb edema (+) is reduced. The results of the
Random blood Glucose examination are 182 mg/dl. The doctor decided to continue the
therapy.
On day 6 of treatment, swelling of the extremities (-), BP = 140/90 mmHg, pulse rate 86 /
minute, regular, breaths 20 times/minute, deep. Temperature 36.5 C, pale (-/-) conjunctiva,
minimal shifting dullness. The results of the Random blood Glucose examination are 150
mg/dl and Hb 10.1 g / dl. The patient is discharged with medications as follows: Furosemide
40 mg (1x1), CaCO3 3x500 mg, Folic acid 3x1, Irbesartan 1x150 mg, Amlodipine 1x10 mg,
diabetic diet, and kidney disease is being explained by nutritionists.
The doctor informs the patient about the possibility of hemodialysis as a kidney replacement
therapy soon. The doctor also recommends a diet plan that is sufficient in calories, low in
protein, and low in salt as well as potassium.
Please discuss the patient's problem with 7 jumps!