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CHAPTER II

CASE REPORT
2.1 Anamnesis
2.1.1 Identification
Name

: Nurdianah Binti Mat Lian

Sex

: Female

Age

: 40 years old

Address

: Jl. Kalpataru 1 No 1322 RT 36 RW 04 Pipa Reja, Kemuning,
Palembang

Status

: Married

Occupation

: None

Religion

: Moeslim

Date of admission: March 9th 2015

(March 10th 2015)
2.1.2 Chief complaint
Worsen shortness of breath since 3 days before admission
2.1.3 Additional complaint
Abdominal enlargement since 2 months before admission
2.1.4 History of present ilness
Two years before admission,patient complaint she had urination 4-5 times
per day, but amount of urine slightly, the colour was dark brown or tea-colored urine.
Patient feel weak and pale. There was decreasing of body weight. An Internist then

came and give medication. She was comfortable in sitting position or sleep with 2 pillows in piles. epigastric pain (-). nausea (-). but ordinary physical activity results in fatigue and dyspnea. vomiting (-). fever (-) and no abnormality in defecation and urination. There was no wheezing. shortness of breath was not influenced by weather or emotions or any specific irritants. vomiting (-).arm) .1. Shortness of breath occurs continuously. Itch (+). patient felt healty and can doing daily activity normally.stomach. Epigastric pain (+). Patient unable to carry out any physical activity without discomfort. appetite was decreased (+). Patient had a ±6 times urinating . the drug have been exhausted. patient complained about shortness of breath following abdominal enlargement . shiver (-).Patient consulted to an internist and was suggested to get hospitalize but patient refused. especially on activity. constipation (-) and swelling whole body (leg.5 History of Present illness   History of high blood pressure since three years ago History of diabetes mellitus Three years before admission. delirious (+). Patient just got medicine and had an improvement. nausea (-). fever (+). She got severe shortness of breath. After taken a medication.feels full. Sometimes.Patient came to RSMH Palembang. Shortness of breath was not influenced by cold weather or exposure to irritants. Two months before admission. Cough (-). patient waking up in midnight because of shortness of breath and sometimes patient can’t sleep caused by shortness of breath. vision was decreased (+). fatigue or weakness and sleepy. patient complained often feel thirsty and hungry. The abdominal enlargement and swelling leg got worse . comfortable at rest. There is a shortness of breath (+).. especially on activity. Three days before admission. 2.

in night. She given a diabetic drug but patient forget what drug she is eaten. There was decreasing of body weight. Patient went to internist every month to control   and taken a diabetic drug.1.2 Physical examination (March 10th 2015) a. The drug is big and white.1.6 Illness history in the Family   History of diabetes mellitus (+) in her father and mother History of hypertension (+) is her father 2.8 C    Habitus Body weight Body height : picnicus : 82 kg (normally before abdominal enlargement: 65 ) : 160 cm . Patient went to internist and knew that she had diabetes mellitus. General examination       General appearance: looked moderately sick Sensorium : compos mentis Blood pressure : 170/90 mmHg Pulse : 88 x/m. regular Respiration o Frequency : 34 x/minute o Rhythm : regular o Type : toraco-abdominal 0 Temperature : 36. History of asthma is denied History wound doesn’t heal is denied 2.7 History Habits    Smoking (-) Drinking alcohol (-) Contact with chemicals (-) 2.

icteric sclera (-).  central. hyperemic mucosal  membrane (-). neck. no enlargement of lymph node. hyperemic pharynx (-). normal pigmentation. symmetrical face. enlargement of tonsil (-). fissure (-). round. hair loss (-). Nose No abnormalities on outer part. tenderness (-) Eyes Exopthalmus or endopthalmus (-).   stomatitis (-).03 kg/ m b. no gum hypertrophy. bleeding (-) Mouth Lips : cyanotic (-). deformity (-). general sweating (+). no efflorescence. ni icteric.  normal turgor. nasal mucus (-). papil atrophy (-). BMI 2 : 32. pale conjunctiva palpebrae (+). subclavicula.  temporal bleeding (-). Lymph nodes No enlargement of submandibular. sianotic (-). tophi (-). light reflex (+). intact eardrum. tremor (-).scar (-). brittle hair (-). aromatic(-) Neck H2O JVP : (5+0)cm . Specific examination  Skin Skin color is white yellowish. Thorax . septal deviation (-). congestion (-). clear cornea. pale on palm and plantar (+). no nuchal rigidity. normal  hearing ability. keilosis (-). and axxilaries lymph  nodes Head Normocephaly. central trachea. tongue : coated tongue (-). incomplete teet. pupil : isokhor. wet on palpation. sweeling of palpebra (-). no enlargement of thyroid gland. diameter 3mm Ear No abnormalities on meatus accusticus externus. tenderness on processus mastoideus (-).

normal mammae. wheezing (-) o Posterior I : static: symmetric. pale on finger (+). rales (+) in the base of right lungs. retraction (-) P : stem fremitus same right and left. venectasis (-).  no pain on percussion. retraction (-) P : stem fremitus same right and left. undulation (+) A: normal bowel sounds Extremity Upper : pain no joint (-). flat surface. venectation (+) P: liver palpable three fingers below the arcus costae. crepitation (-). tenderness (-) P : sonor on left and right lung A : vesicular (+). pale palmar (+). regular. rales (+) in the base of right lungs. spider nevi (-). dynamic : same movement right and left. murmur (-). crepitation (-). dorsum pedis edema (-). clubbing finger (-) Lower : varices (-). no tenderness. tender. thrill (-) P : top border of cor is left ICS II Right border of cor is linea midclavicula dextra Left border of cor is linea axillary anterior sinistra A : HR 88 x/m. gallop (-) Abdomen I: distended. tenderness (-) P : sonor on left and right lung A : vesicular (+).Normal shape. blunt edges. tibial edema (+). spleen in schuffner 8 P: liver dullness (-). wheezing (-)    Heart I : ictus cordis isn”t seen P : ictus cordis isn’t palpated. pitting edema  (+) External genitalia : no examinated . crepitation (-) Lung (pulmo) o Anterior I : static: symmetric. dynamic : same movement right and left. shifting dullness (+).

8 mEq/dL  Uric Acid : 5.1 mg/dl  BSS : 118 mg/dl             Urinalisa (5-10-2015) Colour : yellow Clarity : slightly cloudy Density : 1.6 x 103 / mm3  Hematocrit : 21 % uL  Platelets : 140 x 103 mg/dl  Leukocyte count : 0/3/60/30/7  SGOT : 21 U/l  SGPT : 11 U/l  Ureum : 20 mg/dL  Creatinine : 1.36 mg / dl  Leukocytes : 5.8 mg/dL  Natrium : 142 mEq/dL  Kalium : 3. Laboratory examination Hematology (6-10-2015)  Hb : 7.0 Protein : ++ Glucose : Keton : Blood : Bilirubin : Urubilinogen : 2 Nitrit : Leucosite Esterase : + .3 Additional Examination a.010 pH : 7.4 mg / dl  Erythrocytes : 2.37 mg/dL  Calsium : 7.2.

V5.04 s S on V1 + RV5/V6 <35 ST elevation (-) T inverted I.Nephron USG .MCHC ecamination .GDT.MCV.TIBC .b.4 Additional Examination Planning . ECG         Sinus rythmia Left axis HR 87 x/minute PR interval 0. V6 Conclusion : Lateral iscemia 2.12s ORS complex 0.PA thorax rontgen .Ferritin examination . II.Fe. aVL.Nutrition Consult .

5 Resume A 40 years old women came with severe shortness of breath since 3 days before admission. vision was decreased (+). delirious (+).. Itch (+). Sometimes. vomiting (-). Shortness of breath occurs continuously.arm).feels full. She got severe shortness of breath. She was comfortable in sitting position or sleep with 2 pillows in piles. shiver (-). There was no wheezing. From laboratory examination. especially on activity. Cough (-). nausea (-).6 Working Diagnosis . and swelling whole body (leg.4) and Ht (21).undulation (+) edema pretibial (+) pitting edema (+) and pale of palmar (+). comfortable at rest.stomach. leukosit (5. The abdominal enlargement and swelling leg then got worse .600). and kalium (3. There is a shortness of breath (+). Three days before admission. especially on activity. shortness of breath was not influenced by weather or emotions or any specific irritants. Patient unable to carry out any physical activity without discomfort. fever (+). By physical examination.2. Epigastric pain (+). rales in base of lung (+).37). the drug have been exhausted. pale of conjunctiva palpebrae (+).Patient consulted to an internist and was suggested to get hospitalize but patient refused.increases ureum (20). Patient just got medicine and had an improvement. History of diabetes mellitus and hypertension since 2 years ago. there is decreased Hb (7. but ordinary physical activity results in fatigue and dyspnea. Shortness of breath was not influenced by cold weather or exposure to irritants. patient complained about shortness of breath following abdominal enlargement . appetite was decreased (+). Proteinuria (++) 2.8). Two months before admission. kreatinin (1. patient waking up in midnight because of shortness of breath and sometimes patient can’t sleep caused by shortness of breath. ascites (+).

9 Prognosis Quo ad vitam: Dubia Quo ad functionam: Dubia ad malam Quo ad sanactionam: Dubia ad malam .CKD stage IV e. 2.8 Therapy Non Pharmacology : - Bed rest DM diet Education Oxygen 4 -6 L/m PRC transfusion 450 cc step by step. Pharmacology : - IVFD RL gtt xx/minute Furosemide 1x40gr IV Spinorolacton 1 x 12.c nephropaty 2.7 Differential Diagnosis CKD stage IV ec nhypertension + hypertension stage II + HHD + Anemia e.c diabetes nephropathy + Hypertension stage II + Diabetes Mellitus tipe II + HHD + Anemia e.c chronic disease.5 mg Folic acid 3x1 mg CaCO3 3 x 500 gr Laxadin 2. or Fe deficiency.