Afrida/Female/ 64 y.

o /FW 02

Chief Complaint:
• Decrease of consciousness since 1 days ago
8
Present Illness History

• Decreased of consciousness since 1 day ago. Initially the patient can

still communicate, then the patient be agitated and can not
communicate to others.
• Breathlessness has increased since 1 days ago, has been felt since 3
days ago, affected by activity. not affected weather or food
• Less micturition since a week ago
• Cough since 3 days ago, phlegm (+), blood (-).
• Fever since 1 day ago, high, no chill
• Epigastric pain (+), nausea (-) and vomitus (-)
• History of bleeding (-), nosebleed (-), black stool (-)
• Defecation within normal limit
• Patient already known as hypertension and consumed amlodipine 5
mg po
• Patient already known as Cell B diffuse LMNH from lymph biopsy,
post chemotherapy in 18 jan 2023 with vincristine, doxorubicin,
rituximab
Past Illness History

• History of hypertension (+)

consumtion amlodipine 1x5mg

Family Illness History

• There is no family member get the

similar disease.
Physical Examination

• General Appearance : severe

• Consciousness level : delirium
• BP : 70/40 mmHg
• HR : 114 x/minute
• RR : 25 x/minute
•T : 37 º C
• SaO2 : 97% O2 5lpm via NC
• Eye
–Conjunctiva anemic (-)
–Icteric sclera(-)
• Neck
–JVP 5+0cmH20
• Thorax : normochest VII
• Lung:
–Inspection : Statically : symmetric left and right
dynamically : symmetric left & right
–Palpation : Fremitus same both lung
–Percussion : Sonor
–Auscultation : breath sound broncho vesicular, Rales
+/+, Wh -/-
• Cor: VII
–Inspection : Ictus is not seen
–Palpation : Ictus palpable 1 finger lateral
ICS RIC VI
–Percussion:
•Left border : 1 fingers lateral LMCS ICS VI
•Right border : Linea sternalis dextra
•Upper border : ICS II
–Auscultation : Regular, murmur (-), Gallop (-)
• Abdomen:
–Inspection : Enlargement (-), collateral vein (-),
VII
spyder navy (-)
–Palpation : supel, Hepar and spleen not palpable
–Percussion : Tympani, shifting dullnes (-)
–Auscultation : Bowel sound (+) Normal, Bruit (-)

• Extremities:
–Oedema Pretibia ++/++
–Physiologic Reflex ++/++
–Pathologic Reflex -/-
–CRT < 2”
Laborator
y Items Value
VII

Hb/ht/leuko/trombo 5.0/16/25980/721000
Diff count 0/0/1/90/6/3
MCV/MCH/MCHC 60/19/32
Alb 2.8
PT/APTT/D-dimer 11.9/22.9/3356
SGOT/SGPT 14/13
Ur/Cr 200/2,4
Na/K/Cl 139/5.6/110
BGA 7,443/25.4,8/85.7/18,3/-4,1/97%
AntiHIV/AntiHCV/HBsAg Non reactivective/non reactive/non
reactive
Chest X-Ray VII
Brain ct scan VII
Ulkus dekubitus
ECG VII
Problems
• Decreasee of consciousness
• Pneumonia
• Uremia
• Anemia
• Ulkus decubitus
• Hiperkalemia
• Diabetes mellitus
• Stroke infark
Working Diagnosis

• Decrease of consciousness ec uremic ensefalopaty dd/ sepsis

ascoaited enchepalopathy dd/ sindrom delirium acute
• Acute on chornic kidney diasease
• sepsis ec ulkus decubitus grade 3 dd/ Community acquired
Pneumonia
• Community Acquired pneumonia severe low risk mdr
• Severe Anemia mikromocytic hypochrome cb chornic illness
• DM type 2 uncontrolled normoweight
 Therapy
• Rest/ soft diet low salt low protein die diabetic 1700 kkal gr/
• 02 nc 3lpm
• IVFD Nacl 0,9% 500ml /8 hour
• Ceftriaxone 2 x 1 gr iv
• levofloxacin 1x750mg/ 48 jam iv
• Inj metronidazole 3x500mg iv
• Folic acid 1 x 5 mg po
• Bicarbonate sodium 3 x 500 mg po
• Kalitake 3x1 sach
• Acetylcysteine 3 x 200 mg po
• Paracetamol 3x500mg po
• trf prc 2 unit/hari
Plan

• Kidney Ultrasound
• Hemodialysis
• Culture Sputum
• Culture urine
• Cultur blood
• Urynalisis
• Check SI TIBC ferritin, GDP G2PP HBAIC, profil lipid
• Consult neuro
• Consult vascular surgery for debridemant