1

Budi eka putra/ Male/ 45 Yo / MW 02

Chief Complaint:

• Pain in all abdomen area since 3days ago

Present Illness History

• Pain in all abdomen area since 3days ago and getting worse these days. pain increases
when touched, not triggered by food
• Breathlessness (+) not affected by activity, wheater or food.
• fever (+) since 5days ago, continuous fever, not hight. Nausea (-), vomit (-).
• Defecation is normal, black feces (-), last defecation in this morning, regular color and
consistency.
• Patient post pig tail installation 3weeks ago, on idications of refractory ascites.
• Patient has known with CKD, HD routine every Wednesday and Saturday.
Past illness history

• History of CKD on HD ec pgh

Family illness history

• No family illness history

Drugs history
• Folic acid 1x5mg
• Bicnat 3x500mg
• Amlodipin 1x10mg
• Candesartan 1x16mg
• Clonidine 3x0.3mg
• Carvedilol 2x25mg
 Physical Examination VII

• General Appearance : moderate

• Consciousness level: compos mentis

• BP : 165/90 mmHg

• HR : 90x/minute

• RR : 22 x/minute

• T : 37,2º C

• SaO2 : 98% free air

• 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 2 finger lateral LMCS ICS VI
– Percussion:
• Cardiomegaly (+)
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (+)
– Palpation: undulasi (+) pressing pain in all abdomen area (+),
hepar and spleen difficult to assess.
– Percussion: faint sound
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 6.7 gr/dl
Ht 23%
WBC 12.910/mm3
Platelet 597.000/mm3
MCV/MCH/MCHC 92/27/29
Ur/Cr 77/8,3
Na/K/Cl 136/5.7/102
Chest X-Ray VII
ECG
VII
Problems

- Abdominal pain
- breathlessness
- Fever
Working Diagnosis

- Suspect spontaneous bacterialis peritonitis.

- CKD stage V ec PGH on HD
- Massive Ascites
- CHF NYHA FC II ec HHD
- Moderate normocytic normochromic anemia ec chronic
disease
- Reactive thrombocytosis
- Hiperkalemia
Therapy

-Rest, diet low protein low salt 60gr

- O2 3lpm, nasal canula
- IVFD renxamin 200cc/24hours
- Cefotaxime 3x2gr (iv)
- Folic acid 1x5mg
- Natrium bicarbonate 3x500mg
- Paracetamol 3x500mg
- Kalitake 3x1shac
- Crossmatch PRC 1unit
- PRC transfusion 1unit/day
Plan

- Check complete peripheral blood, urinalysis

- PRC tranfusion