1

Refit / Male / 24 yo/ HCU 17

Chief Complaint:
• Headache increased since 6 hours ago
Present Illness History
• Headache increased since 6 hours ago, Headaches are felt continuously until
can't do activities
• Breathlesness since 2 days ago, affected by activity
• stomach has been getting bigger since 2 weeks ago
• Cough since 3 days ago, not sputum or bleed
• Nausea (-), vomitus (-)
• Fever (-)
• Mixturition is normal.
• Defecation is normal
Past illness history

• History of Hypertension (+)

• History of DM (-)

Family illness history

• No Family had symptoms like this patient.

Physical Examination
VII
• General Appearance : Severe

• Consciousness level: CMC

• BP : 170/140 mmHg

• HR : 87 x/minute

• RR : 24 x/minute

• T : 36º C

• SaO2 :99 %

• VAS : 6
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-) abses on the regio right iliaca
– Palpation: hepar and spleen is not palpable
– Percussion: tympani,
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 8,9 gr/dl
Ht 28 %
WBC 12450 /mm3
Platelet 402000 /mm3
Diff. Count 0/0/87/6/7
PT/APTT 10,3/29
RBG 95
Ur/Cr 81/8,1
SOGT/SGPT 16/16
Na/K/Cl/Ca 135/6,2/106
Alb/glo 2,9/3,5
BGA &,43/36,4/42.8/24,6/0.0/77,8
Chest X-Ray VII
ECG VII
Problems

• Hypertensive emergency
• Imbalance electrolite
• Renal failure
Working Diagnosis

• Hypertensive emergency
• CKD stage V on HD
• Hyperkalemia
• Ascites cb Nephrogenic
• Heart failure stage B NYHA Fc II
• Moderate anemia normocytic normochrom
cb chronic disease
• Hypercoagulable state
Therapy

• Rest/ soft diet low salt 48 gr/ O2 nasal canule 2 l/I

• Ivfd eas pfrimmer 250 cc/24 hours
• Drip nicardipine
• Ceftriaxone 2 x 1 gr iv
• Bicnat 3 x 500 mg po
• Kalitake 3 x 1 sach
• Asam folat 1 x 5 mg po
• ca gluconas 1 amp iv extra
• novorapid 10 iu in 50 cc D40% iv extra
Plan

• Hemodialisa
• Consul neurology departmen
• Consul ophthalmology department
• Echocardiography