IDENTITAS

Nama: Ny. M
Usia : 51 yo
Bangsal : ROI bed C

Chief complaint: shortness of breath worsen + 10 hours before

admission.
Present History illnes : (alloanamnesis+auto)
Patient come to emergency room RSDM with complaint shortness of
breath since +10 hours before admission. Patient feels the tightness
constantly getting worsen, both at rest and when activity (+). The
patient feels slightly better when the half-sitting position. Shortness
of breath is not influenced by emotion (-), weather (-), or certain
foods / beverages (-). Shortness is accompanied by cough(+) cough
without sputum (-) or fever (-). Patient also complained of nausea (+).
Nausea felt + 3 days, without vomiting. Patient said actually this
shortness of complaints has been going on + last 2 months, but felt
heavily lately. Patient also complained about the stomach that feels
more enlarged and feels paced and both legs are also swollen.
Patient felt decreased of appetite.

Currently, the patient admits that she still can urinate even if at least
3-4 times @ ¼-1/2 glass of starfruit, clear yellow color. Urinate pain
denied (-) reddish reddened (-). Patients defecate usually 1 times a
day brownish yellow, black bowel (-) defecate mixed with blood (-)
slimy defecate (-).

+ 1 week before admission the patient said that he had just returned
from hospitalization in RSDM due to a similar complaint, the patient
during the hospitalization underwent extra Hemodialysis and
received blood transfusion. After the extra hemodialysis the patient
feels asphyxiation is greatly reduced and the swelling in the abdomen
and both legs is reduced.

+3 years SMRS patient often sleep using 2-3 pillows, even if the
shortness of the patient sleeps in a half-sitting position. Patients
often feel tightness both at rest and during activities. Patients
admitted to occasional coughing at night, sputum (-), fever (-), also
sometimes swollen legs that felt worsen in the afternoon and slightly
better in the morning.

 +The last 5 years the patient is diagnosed with kidney failure and
routinely undergoing treatment and dialysis in RSDM. Patients
regularly wash the blood once a week on Thursday. In the beginning
before knowing kidney failure, patient often vomiting without reason,
other than that the patient also often feel tightness and swelling on
his legs, before finally checked further and said suffering from kidney
failure and recommended undergoing dialysis. Furthermore, patients
undergo CAPD installation operation and until now using CAPD.
Patients replace dialysate fluid 4 times daily with fluid intake 600-
800cc per day. But it is said recently that patients are only able to take
400 cc fluid per day, clear fluid, abdominal pain is denied (-), the fever
is denied (-).
+7 years SMRS patients know that he suffered from high blood
pressure pain, but the patient rarely checked herself and control to
the doctor. Only occasionally take tension-reducing medication when
it feels heavy head and stiff neck and can not sleep. Patients deny
having a history of high blood sugar.
Past Illness :
Malaria (-)
Dengue hemorrhagic fever (-)
Hepatitis (-)
Typhoid (-)
Measle (-)

Physical Examination :
General Condition: compos mentis E4M6V5
VS : Bp:180/100 HR:116x/m RR:26x/m T: 36,5 C VAS -
Head: normochepal
Eyes: Conjungtiva anemis -/-, sklera ikterik -/-, Light Reflects (+/+),
pupil isokor (+/+)
mouth: Atropy of the tongue papil (-).
Neck: limphonody enlargement (-) , JVP R +4cmH2O
Thorax: normochest, retraction –

Pulmo: I chest movement right=left

P Fremitus both side decreased
P Sonor both sides decreased
P Vesicular both sides decreased
bilateral basal rales +/+

Cor : I Ictus cordis not visible

P Ictus cordis can be feel at ICS V 2cm lateral LMCS
P Heart borders is expand caudolateral
A Heart sound normal, s1-s2 regular, no extra noise

Abd: I Abdominal wall // chest wall

A Bowel sound 12x/menit
P Tympany, tenderness (sde) undulation (-), shifting dullness (+).
 P Tender in palpation, Hepar and Lien normal

Ext : edema ext.inferior +/+

cool superior and inferior extremities -/-

LABORATORIUM
pemeriksaa hasil rujukan pemeriksaan hasil rujukan
n
Hb 9,6 PT -
AL 7,8 APTT -
AT 287 INR -
Hct 27 GDS 153
Mcv 85,1 SGOT 50
Mch 29,9 SGPT 22
Eos 4,7 Bil tot 0.8
Bas 0,3 albumin 3.0
netrofil 60 Ureum 65
Limfosit 27,60 Creatinin 8.7
monosit 7.40 Natrium 137
Kalium 3.2
hbSag NR Calsium 1,07
Alkalosis respiratorik belum terkompensasi

ECG

Sinus takikardi, HR 110 /minute, extreme RAD, ZT V4-V5 CWR, LVH

Ro thorax PA
Problem list.
1. CKD 5 PD with edema pulmonum
2. CHF NYHA IV a. LVH e. HHD
3. HT stage II
4. Mild hipoalbuminemia

No. Problem list

1. CKD 5 PD with edema pulmonum
 Assesment :
Anam: shortness of breath since + 10 hours before
admission
History of kidney failure with CAPD
Physical exam: RR =26
Pulmo : rales (+/+)
Lab findings : Cr= 8.7 Ur= 65
Ro thorax : oedem pulmonum
Dd/ etiology : CKD
Plan Dx : -
Dd/ complication: breating failure, encephalopathy
uremikum, asidosis metabolic
Plan Th/
INTENSIVE CARE
HEMODIALISIS EXTRA
- Bedrest ½ sitting position
- O2 8 lpm NRM
- Diet 1500Kcal
- Inf as keto 1 flash/ 24 hours
- Candesartan 16 mg/ 24 hours
- Clonidin 0,15 mg/12 hours
- Folic acid 800mcg/ 24 hours
- Caco3 1 tab/ 8 hours
- DC

Monitor: vital sign, fluid balance

2. CHF NYHA IV a. LVH e. HHD

Anam :history of high blood pressure, 3 years often sleep
using 2-3 pillows, even if the shortness of the patient sleeps
in a half-sitting position. Patients often feel tightness both at
rest and during activities. Patients admitted to occasional
coughing at night, also sometimes swollen legs that felt
worsen in the afternoon and slightly better in the morning.

Physical exam:
T = 180/100
RR = 26
JVP R+4 cm H20
Rales (+/+)
cardiomegaly
Lab findings : ro thorax : cardiomegaly
Dd/ etiology : HT
Plan Dx : echo, profil lipid
Dd/ complication: acute heart failure
Plan Th/:
- O2 8-10 lpm NRM
- inj furosemid 40 mg/ 8hours
- Candesartan 16 mg/ 24 hours
- Clonidin 0,15 mg/12 hours
- DC

Monitor: vital sign, BC

3. HT stage II
Anam : present illness history having HT since 7 years ago,
not control routinely
Physical exam: BP : 180/ 100. N: 110. Rr:26.
Lab findings : -
Dd/ etiology : essensial/ idiopatik
Plan Dx : profil lipid, funduskopi
Dd/ complication: CKD, CVA
Plan Th
- Candesartan 16 mg/ 24 hours
- Clonidin 0,15 mg/12 hours
Monitor: KUVS

4. Mild hipoalbuminemia
Anam : decrease of appetite, swollen in both of legs,
stomach enlargement
Pf : shifting dulness (+), oedema ekstemitas inf (+/+)
Lab finding : alb =3.0
Dd etiology : low intake, excess excretion
Plan Dx : urin routine, albumin urine
Dd complication : -
Plan Th : vipalbumin 1 cap/ 8 jam
Monitor : alb/ 3 days