CASE REPORT

A 51 -year old male

presented with
shortness of breath

ALISYA NADHILAH CHAIRUL NOOR

030.15.013
INTERNAL MEDICINE DEPARTEMENT-
TRISAKTI UNIVERSITY
 PATIENT'S IDENTITY

Name : Tn. M
No.RM : 00.60.91.79
Gender : Male
Age : 51 years old
Address : Ciherang
Religion : Islam
Ethnic Group : Sundanese
Profession : Farmer
Last Education : SMP
Marital Status : Married
Date of Entry : 31/07/2019
Room : Rengasdengklok R.202
 ANAMNESIS
WAS DONE BY AUTOANAMNESIS WITH THE
PATIENT ON 02/08/2019, 11.00 AM. IN
RENGASDENGKLOK- ROOM 202
 CHIEF COMPLAINT

Shortness of breath
since 1 day before
going to the hospital
 ADDITIONAL
COMPLAINTS
• Cough of phlegm
• Difficulty of breathing
• Lethargic (+)
• Nausea (+), Vomiting (+) 1x
contain food and water
• Swollen lower extremities
• Difficulty of defecation
• Loss of appetite
• Difficulty of sleeping
 Present Medical History

Swollen lower Difficulty of breathing Cough of phlegm Shortness of

extremities since since 4 days after HD since 3 days ago breath since 1 day
1 month before going to
Occurs suddenly when the hospital
during the activity and Nausea (+),
got better at rest vomiting (+)
 PATIENT'S HISTORY

PAST HABIT'S MEDICATION

FAMILY'S
MEDICAL HISTORY HISTORY
HISTORY
HISTORY He didn't routinely
Hypertension (-) Smoked up 1
Patient had consumed the anti
DM (-) pack of hypertension drug
hypertension cigarettes a day and go to the
from 2018 hospital for control
 PHYSICAL
EXAMINATION
 General Vital Sign
Condition Temperature : 36,1 ºC
Moderate
pain Blood pressure : 200/130 mmHg
Consciousness
Composmentis Heart rate : 112x/min
GCS : 15 Respiratory rate 40x/min
Nutritional Status
Oxygen Saturation :
Weight: 61 kg 95%
Height: 174 cm
BMI: 20,14
(Normal)
General Status
General Status
General Status
Outline of
Topics
LABORATORY
RESULTS
31/07/2019
LABORATORY
RESULTS
01/08/2019
WORKING DIFFERENTIAL
DIAGNOSIS DIAGNOSIS
ANEMIA EC RENAL ACUTE KIDNEY INJURY
C K D S TA G E V CHRONIC GLOMERULONEFRITIS
H Y P E R T E N S I O N S TA G E 2 NEPHROSCLEROSIS
 1. IVFD NaCl 0,9% 8 tpm
2. Furosemide 2x40mg (IV)
3. Ceftriaxone 1x2gr (IV)
4. Dexamethasone 3x1 ampul (IV)
Therapy 5. CaCO3 3x1 tab
6. Folat Acid 3x1 tab
7. Bicnat 3x1 tab
8. Amlodipin 1x10 mg (1x1 tablet)
9. Valsartan 1x 16mg (1x1 tab)
10. PRC Transfusion 2 kolf
 AD VITAM : DUBIA AD MALAM
Prognosis AD FUNCTIONAM : DUBIA AD MALAM
AD SANATIONAM : DUBIA AD MALAM
 IN T EN DED IMP ACT

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FOLLOW UP DAY 1
 IN T EN DED IMP ACT

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Presentations are tools that can

be used as lectures, reports, and
more. Most of the time, they’re
presented before an audience.

FOLLOW UP
DAY 2
 FOLLOW UP
DAY 3

IN T EN DED IMP ACT

T A R GET A UDIE N CE

Presentations are tools that can

be used as lectures, reports, and
more. Most of the time, they’re
presented before an audience.
 FOLLOW UP
DAY 4-5
IN T EN DED IMP ACT

T A R GET A UDIE N CE

Presentations are tools that can

be used as lectures, reports, and
more. Most of the time, they’re
presented before an audience.
 HISTORY SUPPORTIVE
• Shortnes of breath PHYSICAL EXAMINATION :
• Cough with phlegm
EXAMINATION
• Hb : 6 g/dL
• Swollen in lower • BP : 200/130 mmHg
• Eritrosit : 2.2 x 106/ul
extremities • RR : 40x /min
• Leukosit: 16.270/ ul
• Nausea, vomiting, • Conjungtiva Anemic • Hematokrit: 18.9%
lethargic, loss of
• Ronkhi +/+ • Ureum : 131.1 mg/dL
appetite were also
• Edema in lower • Creatinin: 12.8 mg/dL
complained
• Was diagnosed as extremities
• GFR
hypertension in 2018 = 8,07 ml/mn/1,73m2
(STAGE V)
Working diagnosis &
differential diagnosis

Therapy
 EXAMINATION PLAN

•USG
•Rotgen thorax
•EKG
Thank you!

ANY QUESTIONS?.