1

Mahyudin Rosa , male, 49 yo, mw 02

Chief Complaint: (autoanamnesis and alloanamnesis)
• Accsess Hemodialisa is not fluent since 1 days ago.
Present Illness History :
• Accsess Hemodialisa is not fluent since 1 days ago.
• Fever (-) no shortness of breath (-) no cough (-)
• Headache(-)
• Vomit and nausea (-)
• micturition was decresse since 6 motnh ago
• Defecation was normal
• Patient was prepared to repair CDL
• the patient has been known with CKD std V since 6 month
ago, get routine HD each monday and thursday
Past illness history

• Hypertension (+) since 5 yeas ago

• DM (-)

Family illness history

There is no family member get the similar disease.

Physical Examination
VII

• General Appearance : moderate

• Consciousness level : CMC

• BP : 210/110 mmHg

• HR : 86 bpm

• RR : 19

• T : 36.7 º C

• SaO2 : 98 % room air

• Head, Eye, Mouth & Neck
 Head : Normocephalic, VII
 Conjunctiva : anemis (-/-), icteric (-/-)
 Mouth : Oral ulcer (-)
 Neck : Jugular Vein Dystention (-) lymph node
enlargement (-)
• Lung:
 Inspection : Symmetric
 Palpation : Fremitus left and right was same
 Percussion : sonor
 Auscultation : vesicular, rhales (-/-), wheezing (-/-)
• 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 (-)
– Palpation : hepar and lien unpalpable
– Percussion : tympani
– Auscultation : bowel sound (+) N

• Extremities:
• - Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
Items Value
Hb : 10,1 gr/dl VII
Ht : 29 %
WBC : 7.650 /mm3
Platelet : 238.000 /mm3
Diff. Count. : 0/4/63/24/9
MCV/MCH/MCHC : 77/27/35
PT/APTT/ d dimer : 10,0/28,1
Ur/Cr : 60/5,2 mg/dL
Na/K/Cl/Ca : 141/3,9/108 Mmol/L
SGOT/SGPT : 9/6
RBG : 136 mg/dL
Ph/pco2/po2/hco3-/BE/SO :
Chest X-Ray VII
ECG
Problems

• Pro repair CDL

• HT emergency
• Chronic kidney disease
Working Diagnosis

• Chornic Kidney Disease std V cb Hypertension Kidney Disease with

Malfunction CDL
• Hypertention Emergency
Therapy

• Bed Rest/ diet low salt low protein 48 gr

• IVFD Renxamin 200cc/ 12 Hours
• Drip Nicardipine 1 amp (10 mg) in 48 cc nacl 0.9% via syrng pump speed 7.5 cc /hour
• Amlodipin 1x10mg
• Candesartan 1x16mg
• Clonidine 3x0,15mg
• Natrium bicarbonate 3x500mg
• Asam folat 1x5mg
Plan

• Repair CDL
• Hemodialisis