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  • Lapjag Prapto

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    Alyando dr
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    Prapto, a 43-year-old male, presented with breathlessness for 2 days that increased with moderate activity, weakness and tiredness for 1 week, and epigastric pain for 1 week. On examination, he had a heart rate of 75 beats/min, blood pressure of 110/80 mmHg, respiratory rate of 24 breaths/min, and oxygen saturation of 98%. Tests showed signs of congestive heart failure, community-acquired pneumonia, acute kidney injury stage 1 from prerenal causes due to dehydration, and dyspepsia. He was prescribed rest, IV fluids, diuretics, proton pump inhibitors, antacids, and anti-nausea medication, along with

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    Laporan kasus

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    Prapto, a 43-year-old male, presented with breathlessness for 2 days that increased with moderate activity, weakness and tiredness for 1 week, and epigastric pain for 1 week. On examination, he had a heart rate of 75 beats/min, blood pressure of 110/80 mmHg, respiratory rate of 24 breaths/min, and oxygen saturation of 98%. Tests showed signs of congestive heart failure, community-acquired pneumonia, acute kidney injury stage 1 from prerenal causes due to dehydration, and dyspepsia. He was prescribed rest, IV fluids, diuretics, proton pump inhibitors, antacids, and anti-nausea medication, along with

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    © All Rights Reserved
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    33 views2 pages

    Lapjag Prapto

    Uploaded by

    Alyando dr
    Prapto, a 43-year-old male, presented with breathlessness for 2 days that increased with moderate activity, weakness and tiredness for 1 week, and epigastric pain for 1 week. On examination, he had a heart rate of 75 beats/min, blood pressure of 110/80 mmHg, respiratory rate of 24 breaths/min, and oxygen saturation of 98%. Tests showed signs of congestive heart failure, community-acquired pneumonia, acute kidney injury stage 1 from prerenal causes due to dehydration, and dyspepsia. He was prescribed rest, IV fluids, diuretics, proton pump inhibitors, antacids, and anti-nausea medication, along with

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 2

    Prapto/male/ 43 years/ FW 12 Laboratorium

    Chief Complaint: Breathlesness since 2 days ago. Hb 13,5 PT


    Breathlesness since 2 days ago.increase with moderate activity . Sleep using 2 pillows since 1 week ago.
    Feels weak and tired since 1 weeks ago Ht 41 APPT
    Epigastric pain since 1 week ago Leukosit 10.710 Ur
    Nausea (+) since 1 week ago
    Riw DM (-), Riw HT (+) Trombosit 139.000 Cr
    General appearance : moderate, Consciousness level : CMC, BP : 110/80mmHg, Pulse : 75x/min, RR: 24x/ minute, T :36.7 oC
    ABG 7,48 /21,2 Natrium
    SPo2 : 98 %
    /114,2 /16,1 /-4,7 Kalium
    /99% Chlorida
    Eye: conjunctiva anemic (-) Sclera icteric (-) ,
    INR 1,43
    JVP: 5+2 cm H2O
    Hb 13,5 PT
    Cor: Inspection: ictus is not seen. ,Palpation: ictus is palpated at 2 finger lateral LMCS ICS V-VI , Percussion: cardiomegaly (+) , Auscultation:
    Heart sound I and II regular, murmur (-), gallop (-) Ht 41 APPT
    Pulmo: Inspection: symmetric right =left Leukosit 10.710 Ur
    Percussion: sonor both of lung
    Auscultation: sound of breath , bronkovesicular, Rhale +/+, Wh -/-

    Abdomen: Inspection: simetris.


    Palpation: epigastric pain (-), hepar and lien is not palpable.
    Percussion: tympani
    Auscultation: bowel sound (+).
    Extremity : warm extremity, CRT <2s, edema (+)
    Diagnosis :
    - CHF NYHA FC II
    - Community Acquired Pneumonia
    - AKI stage I ec prerenal ec dehydration
    - Syndrome Dispepsia epigastric pain
    Problem Therapy Plan
    • Rest/ DJ II • Echocardiography
    • Breathlesness • IVFD NaCl 0,9% 24 hours / kolf • Profil Lipid check
    • Weak and tired • Drip Furosemid i.v
    • Lansoprazol 1x30 mg
    • Sucralfat syr 3x10 cth
    • Domperidone 3x10mg PO

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