Agusma Yenti/female/54 y.

o/ HCU 09

Chief Complaint:
• Fatigue and weakness has increased since 3
days ago
9
Present Illness History
• Fatigue and weakness has increased since 3
days ago. fatigue has been felt since 1 week
ago. feeling tired even while resting.
• Pale since 1 week ago.
• Headache felt since 3 days ago.
• History of bleeding (-).
• Breathlessness (-).
• Fever and cough (-)
• Nausea and vomiting (-).
• Chest pain (-)
• Micturition and defecation are normal limit
Past Illness History

• History of Hypertension(+) since 1 years ago

but not routine consume medicine
• History of Diabetes Mellitus (-)
• History of heart disease (-)

Family Illness History

• There is no family member get the similar

disease.
Physical Examination

• General Appearance : severe

• Consciousness level : CMC
• BP : 170/100 mmHg
• HR : 85 x/minute
• RR : 20 x/minute
•T : 36.5 º C
• SaO2 : 98% NC 5 liter per menit
• Eye
– Conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Thorax : normochest VII

• Lung:
–Inspection : Statically : symmetric &
dynamically : symmetric
–Palpation : Fremitus left = right
–Percussion : Sonor
–Auscultation : breath sound vesicular, Rh -/- , Wh
-/-
• Cor: VII
–Inspection : Ictus is not seen
–Palpation : Ictus palpable 1 finger medial ICS RIC V
–Percussion:
• Left border : 1 fingers medial LMCS ICS V
• Right border : Linea sternalis dextra
• Upper border : ICS II
–Auscultation : Regular, murmur (-), Gallop S3 (-)
• Abdomen: VII
–Inspection : Enlargement (-)
–Palpation : supel, hepar and liet not palpable
–Percussion : Tympani
–Auscultation : Bowel sound (+) Normal, Bruit (-)

• Extremities:
–Oedema Pretibia -/-
–Physiologic Reflex +/+
–Pathologic Reflex -/-
–CRT < 2”
Laborator
y VII

Items Value
Hb/ht/leuko/trombo 6.9/17/6.080/138.000
DC 0/0//83/9/8
PT/aPTT 10/26
RBG 111
Alb/glb 3.1/2.9
Ur/Cr 116/8.3
Na/K/Cl 96/3.9/73
HBsAg/AntiHIV/AntiHCV Non reactive/NR/NR
BGA 7.505/18/184/14.3/-7/99
 VII
Chest X-Ray
ECG VII
Problems
• Renal failure
• Hyponatremia
• Anemia
• Hypertension
Working Diagnosis

• Chronic kidney disease cb hypertensive kidney disease pro HD

• Hyponatremia hypoosmolar euvolemic cb renal failure
• Moderate anemia normocytic normochrome cb chronic disease
• Hypertension Stage II
• Ischemic Myocard Septal
Therapy
• Rest/ Diet Low salt low protein 48 gr/ 02 3 lpm NK
• IVFD NaCL 3 % 1 kolf/ 12 hours (3 kolf)
• IVFD Renxamin 200 cc/ 24 jam
• Folic acid 1 x 5 mg po
• natrium bicarbonate 3 x 500 mg po
• Salt capsule 3 x 500 mg po
• amlodipin 1 x 10 mg
• candesartan 1 x 16 mg po
• Transfusi PRC 1 unit
Plan

• USG Kidney
• Urine Osmolarities
• Urine electrolyte
• Hemodialysis
• Troponin I