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    Junaidi Badri - DR Rezki

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    Rezki Pratama Sadeli
    1. 48 year old male presented with increased paleness over the past week and a history of hypertension and chronic kidney disease stage 5 requiring regular hemodialysis. 2. On examination, he was found to be anemic with a hemoglobin level of 5.9 gr/dl. 3. He was diagnosed with severe anemia secondary to his chronic kidney disease and treated with IV fluids, supplements, and a planned PRBC transfusion to raise his hemoglobin over 8 gr/dl.

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    Junaidi Badri - DR Rezki

    Uploaded by

    Rezki Pratama Sadeli
    9 views9 pages
    1. 48 year old male presented with increased paleness over the past week and a history of hypertension and chronic kidney disease stage 5 requiring regular hemodialysis. 2. On examination, he was found to be anemic with a hemoglobin level of 5.9 gr/dl. 3. He was diagnosed with severe anemia secondary to his chronic kidney disease and treated with IV fluids, supplements, and a planned PRBC transfusion to raise his hemoglobin over 8 gr/dl.

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    lapjag

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    Junaidi Badri- Dr Rezki

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    1. 48 year old male presented with increased paleness over the past week and a history of hypertension and chronic kidney disease stage 5 requiring regular hemodialysis. 2. On examination, he was found to be anemic with a hemoglobin level of 5.9 gr/dl. 3. He was diagnosed with severe anemia secondary to his chronic kidney disease and treated with IV fluids, supplements, and a planned PRBC transfusion to raise his hemoglobin over 8 gr/dl.

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    Download as PPT, PDF, TXT or read online from Scribd
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    9 views9 pages

    Junaidi Badri - DR Rezki

    Uploaded by

    Rezki Pratama Sadeli
    1. 48 year old male presented with increased paleness over the past week and a history of hypertension and chronic kidney disease stage 5 requiring regular hemodialysis. 2. On examination, he was found to be anemic with a hemoglobin level of 5.9 gr/dl. 3. He was diagnosed with severe anemia secondary to his chronic kidney disease and treated with IV fluids, supplements, and a planned PRBC transfusion to raise his hemoglobin over 8 gr/dl.

    Copyright:

    © All Rights Reserved
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    of 9

    Junaidi Badri ,48 yo male, mw 16

    Chief Complaint
    •pale increased since 1 days ago
    Present Illness History
    • pale increased since 1 days ago. this had been felt
    since 1 week ago
    • nausea and vomiting (-)
    • history of bleeding was denied
    • breathlessness was denied
    • history of hypertention (+) taking medicine regularly
    • micturition was normal
    • defecation was normal
    • patient was known with CKD stg V since january
    2017 and on routine Haemodialisa
    PAST ILNESS HISTORY :
    •History of DM (-)
    •History of hypertension (+) since 5 years ago
    •history of hepatitis (-)

    FAMILY HISTORY :
    •History of same illness (-)

    2
    General Examination
    • Counsciousness : cmc
    • Blood Pressure : 170/100 mmHg
    • Heart Rate : 80x/mnt
    • Temperature : 37 C
    • Respiratory Rate : 18 x/mnt
    • Cyanosis :-
    • Edema :-
    • Anemic :+
    • Icteric :-
    Skin
    Turgor was normal

    Lymph nodes
    • enlargement (-)

    Neck
    Jvp : 5-2cmH2O
    Tyroid : not palpable

    Head
    • Normocephal

    Eyes
    • Anemic (+/+), icteric (-/-)
    Lung:
    -Insp : symmetrical static and dynamic
    -Palp : fremitus left=right
    -Perc : sonor
    -Ausc : vesikuler , ronchi -/- , wheezing -/-

    Heart
    -Insp : ictus unseen
    -Palp : ictus 1 finger medial of LMCS RIC V
    -Perc : left : 1 finger medial of LMCS RIC V,right :
    LSD, upper: RIC II
    -Ausc : Regular rhythm, murmur (-)
    Abdomen
    -Insp : enlargement of abdomen (-)
    -Palp : Liver and lien unpalpable
    -Perc : tympani
    -ausc : bowel sound (+) normal

    Back
    • costovertebral pain (-)

    Extremities
    Udem -/- Physiologic R +/+, Pathologic R -/-

    6
    Laboratory Values

    Hb 5,9 gr/dl
    Leucocyte 7.280 /mm3
    Thrombocyte 143.000 /mm3
    ht 17%

    ur/cr 98/8,5 mg/dl


    RBG 99 mg/dl
    ckd epi 7
    Working Diagnosis
    •severe anemia ec chronic kidney disease
    •CKD stg V ec nephosclerosis hipertention on
    Haemodialisa
    Therapy
    • rest / low protein 40 gr low salt II
    • IVFD easpfrimmer 500cc/24 hours
    • folic acid 1 x 5 mg
    • bicnat 3 x 500 mg
    • amlodipin 1 x 10 mg
    • candesartan 1 x 16 mg
    • PRC transfussion ≥ 8 gr/dl

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