5 Kiamah/Female/54 yo/FW 16

Chief Complaint:
◦ Breathlessness increased since 1 day ago.

Present Illness History

• Breathlessness increased since 1 day ago, has been felt since 1 month ago, not affected by
activity, food, and weather. No wheezing’s heard. History of patient slept with 2 pillows (-)
, often awaked at night (-)
• Fatigue and weakness increased since 1 month ago
• Epigastric pain since 2 days ago.
◦ Cough since 3 days ago, phlegm (+)
◦ Fever since 1 day ago, not high, not chills, not sweat
◦ No nausea and vomit.
◦ Less urination since 2 months ago
◦ Defecation was normal.
• Patient had been referred from district hospital due to Chronic kidney disease
Past illness history

• History of Hypertension (+) since 4 years

ago
• History of DM (-)

Family illness history

• There is no family with the same illness

Physical Examination
VII

• General Appearance : Moderate

• Consciousness level: Composmentis

• BP : 198/108

• HR : 98x/minute

• RR : 26x/minute

• T : 37,1º C

• SaO2 : 99% on NRM 10 lpm

• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5+0 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right and left symmetric
– Percussion: sonor
– Auscultation: Bronchovesicular, Rh +/+, Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger lateral LMCS RIC VI
– Percussion:
• Left border: 1 finger lateral LMCS ICS VI
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen are not palpable
– Percussion: tymphany
– Auscultation: bowel sound (+) Normal

• Extremities:
– Oedema pretibial -/-
Laboratory
Items Value
Hb 5,9 gr/dl VII
Ht 18 %
WBC 5.010/mm3
Platelet 196.000/mm3
Ur/Cr 124/12,4 mg/dl
RBG 122 mg/dl
Na/K/Cl 141/5,1/112
BGA 7,406/23,2/38,7/14,7/-8,4/75,2
Chest X-Ray VII
ECG VII
Problem

- Hypertension
- Pneumonia
- Anemia
- Cardiomegaly
- Pleural effusion
Working Diagnosis

- Hypertension Emergency
- Chronic Kidney Disease stage V cb Hypertension Kidney Disease
- Community Acquired Pneumonia non severe low risk MDR with right
pleural effusion and respiratory failure type 1
- Severe anemia normocyctic normochrome cb chronic disease
- Cardiomegaly without heart failure
Therapy
• Rest/ Reguler diet, low protein low salt 48 gram/day
• IVFD renxamin 1 kolf/24 hours
• O2 NRM 10 lpm
• Drip nicardipine up titration
• Inj Ceftriaxon 2x1 gr IV
• Azithromycin 1x500mg po
• Folic Acid 1x5mg po
• Bicarbonat sodium 3x 500mg po
• Amlodipin 1x10mg po
• Candesartan 1x16mg
• Clonidin 3x 0,15 mg po
• Paracetamol 3x500mg po
• Acetylsistein 3x200mg po
• Crossmatch PRC 2 unit
• Transfusion PRC 1 unit/day
Plan
• CDL and Hemodialysis
• Sputum culture
• Echocardiography