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Name

/ sex / age : Mr. H, Male, 43 yo Address : Wadas Cikampek Religion : Islam Marital status : Married Occupation : meatball seller Date of admission : 14th January 2011

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anamnesis was taken at RSUD Karawang on 17th January 2011 Chief complaint : The patient has been having severe headache for 1 week before admitting to the Emergency unit of RSUD Karawang. Additional Complaint : Dizziness, nausea, chest pain and shortness of breath.

The patient has been having severe headache for 1 week before admitting to the Emergency unit of RSUD Karawang. The pain is throbbing, occurs in spasms, and is felt at the back or top of the head, It suddenly appears, and disappear if he lied down. The patient has been having pain in her chest for 3 days. The pain suddenly appears and spread to his back. It took less than 10 minutes and relieved by rest.

Sometimes he feels shortness of breath if he was doing hard activities. Patient also complained of nausea. But not continue with vomiting. Patient declined oh having cough and excessive exercise. The patient declined of having any abnormalities of his urination and defecation. He said that he had been using anti hypertension drugs for a long time.

The

patient admitted of having the similar condition previously in his life for five years The patient decline of having diabetes mellitus and any kind of disease of the heart, lung, and liver. The patient decline of having allergy to certain food or drug. The patient decline of having history of serious disease or condition that make him hospitalize.

The

patient said that his daughter and his father also have the same disease that he suffers The patient decline of having family with diabetes mellitus and any kind of disease of heart, lung and liver. The patient decline of having family with allergy to any kind of subject.

The patient stated that : He does not smoke He does not consume alcohol He has enough sleep time per day He eat 3 time per day and also drink coffee He doesnt do physical exercise regularly

General

Condition : Moderately ill Consciousness : Compos Mentis BMI weight : 73 kg heigh : 170 cm BMI : 25, 4 (overweight)

Vital

Sign

Blood

Pressure : 180/ 110 mmHg Pulse Rate : 96 times / minute Temperature : 36,50 Celsius Breath Rate : 28 times / minute

Head : Normocephali Eyes :

Anemic conjunctivae (-) / (-) Icteric Sclera (-) / (-)

JVP : normal Lymph gland is not palpable Thyroid gland is not palpable

Inspection Palpation

: flat

Percussion

No pain present on palpation at all abdominal region No liver and spleen enlargement No pain present on abdominal percussion Sounds tympani Normal bowel sound

Auscultation

No

cold and cyanotic extremity No edema is found in all extremities

Test Hemoglobin Leukocyte Thrombocyte Hematocryte GDS Ureum Creatinine Natrium Kalium

Result 13 gram % 6.100 232.000 41 % 109 mg/dl 44,2 mg/dl 0,73 mg/dl 142 mmol/L 3,8 mmol/L

Normal Level 12 - 17 gram % 5000 10000 150.000 - 450.000 37 48 % 80 140 mg/dl 10 45 mg/dl 0,4 1,5 mg/dl 134 145 mmol/L 3,5 5,6 mmol/L

The test was taken on 16th January 2011

ECG

normal

Headache,

lied down. Pain in chest for 3 days suddenly appears and spread to his back. Shortness of breath if he was doing hard activities Nausea, not continue with vomiting had been using anti hypertension drugs for a long time admitted of having the similar condition previously in his life for five years his daughter and father also have the same disease that he suffers Blood Pressure : 180 / 110 mmHg

suddenly appears, and disappear if he

Differential

diagnosis

1. Hypertension

grade II 2. Left Heart Failure 3. Angina Pectoris 4. Myocardial infarction


Working

diagnosis Hypertension Grade II

Klasifikasi Tekanan darah menurut JNC VII Kategori Normal Prahipertensi Hipertensi derajat 1 Hipertensi derajat 2 Sistolik <120 120 139 14 0 159 160 dan atau atau atau Diastolik <80 80 89 90 99 100

Working diagnosis Hypertension Grade II

Laboratory

: Renal function Rontgen thorax Cardiac enzyme

Non

medikamentosa

Educate patients about their illness, particularly by reassuring them that the illness is a serious threat to their physical health and need drugs for a life time Lifestyle modification

Medikamentosa 1. Captopril

25 mg 2x1 2. HCT 25 mg 1x1

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