wirahastuti/Female/40 yo/FW 10

Chief Complaint:
• Fatigue and weakness since 3 days ago .
Present Illness History
• Fatigue and weakness since 3 days ago. feeling weak all day long. Looks
pale since 1 weeks
• Patiens have shortness of breath especially at night and difficult to
sleep.sleep using 2 or 3 pillows. suddenly wake up due to shortness of
breath. Shortness of breath decrease at rest and worse in activity and
not affected with wheather or food.
• cough without phlegm, 1 week ago
• There is no fever.
• Patient has been diagnosed with CKD Stage V on HD, regular HD at
Monday and thursday in RSUP M Djamil
• Patient cant urinate like a usual at first get HD in desember 2021
Past illness history

• CKD Stage V on HD, regular HD at Monday and thursday in

RSUP M Djamil
• Hypertension +
• History of DM (-)

Family illness history

• No family have the same complaint with patient

Drug history

• Clonidin
• carvedilol
• Amlodipine
• Candesartan
Physical Examination VII

• General Appearance : Moderate

• Consciousness level: CM

• BP : 167/100mmHg

• HR : 74 x/minute

• RR : 21 x/minute

• T : 36,7º C

• SpO2 : 97 %
• Eye
– conjunctiva anemic (+/+), icteric sclera (-/-)
VII
• Neck
– JVP 5-2cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus tactile right=left
– Percussion: sonor +/+
– Auscultation: ves+/+ , Rh -/- , Wheezing -/-
• Cor:
– Inspection: ictus cordis is not seen
– Palpation: ictus is palpated at 1 finger lateral LMCS ICS V
– Percussion:
• Left border: 1 finger lateral LMCS ICS V sinistra
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: s1-2 regular, murmur (-)
• Abdomen: VII
– I: flat,
– A: bowel sound + normal
– P: epigastric pain -,hepar and spleen is not palpable,
– Per: timpani, shifting dullnes -

• Extremities:
– Oedema +/+ ,warm sianosis-,crt< 2 sec
• Anogenital:
– normal finding
Laboratory
Items Value
VII
Hb 7.5 gr/dl

Ht 24%

Leukosit 5.760/mm3

Platelet 310.000/mm3

eritrocyte 2.62

Reticulocyte 1.45

DC 0/5/76/13/6

MCV/MCH/MCHC 90/29/32

Ur/Cr 60/5

PT/APTT 11/24.6
INR 1.2

D-dimer 4064
Laboratory
Items Value
VII
Alb/Glb 3.7/4.3

OT/PT 17/9

Na/K/Cl 140/4.2/103

kalsium 10.8
RBG 93

Arterial Blood Gas (ABG) 7.470/34/181/24.7/1/100

Chest X-Ray VII
ECG
Problems

• Shortness of breath
• anemia
 deficiency
Working Diagnosis

• Moderate anemia normocytic normochrome cb chronic disease cb

eritopoiten deficiency
• CHF NYHA FC II ec HHD EF 26%
• Chronic Kidney disease stage V CB Hypertension kidney disease on HD
• Hypertension grade 2
• Bilateral pleural effusion
Therapy

• Rest/ diet MB DJ low salt 50 gram

• IVFD Renxamine 200cc/24 hours
• Amlodipine 1x10mg oral
• Candesartan 1x16mg oral
• Clonidine 1x1 tab oral
• Carvedilol 2x6.25mg oral
• Folic acid 1x5mg oral
• Bicarbonate natrium 3x500mg oral
Plan

Complet Blood count

Urinalysis
Iron Profil
USG Thorax