Nov 14th ,2017

dr. Rudi Erwin

 Afnarita, Female, 50yo, FW03

 Cc:

 Shortness of breath increased since 2 days ago

 Present Illness History

 Shortness of breath incresed since 2 days ago. Shortness of breath affected
by activity and not affected by weather and food. PND (+), DOE (+), OP (+).
 Nausea and vomite since 2 weeks ago. Freq 2-3x/days. Volume ¼ - ½
glass/x vomite.
 Pale since 2 weeks ago.
 Fatiue since 2 weeks ago.
 History of spontanious bleeding (-)
 Cough since 1 week ago. Sputum (+) and yellowish color. Bloody cough (-).
 Fever since 5 days ago. Not too high. No chill and no exessive sweating.
 Decreased of appatite (+)
 Decreased of body weight (+)
 Micturation and defecation normal
 
Past Illness History
• History of DM (+) since 5 years ago. Not regularly controlled.
• History of HT (+) since 2 days ago. Not regularly controlled.

Family Illness History

• Nothing family with the same of diasease
 Physical Examination

 Consciousness level : CMC

 BP : 150/90 mmHg

 HR : 74x/minute

 RR : 24x/minute

 T: 36,4 C
 Eye
 Conjunctiva are anemic +/+
 Sclera are icteric -/-

 Neck
 JVP 5+3 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: right = left fremitus
 Percussion: dull
 Auscultation: Bronchovesicular, rales +/+ at middle right
lung , wheezing -/-
 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 2 finger lateral LMCS RIC VI
 Percussion:
 Left border: 2 finger lateral LMCS ICS VI
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema +/+
 Laboratory

Hb 8,7 gr/dl
 PH 7.27
Ht 25% PCO2 23
WBC 13.680/mm3 PO2 74
Platelet 281.000/mm3 HCO3- 10,6
MCV/MCH/MCHC 78/27/35 BEecf -16,3
Ur/Cr 204/8,4 SO2 82%  97%
CKD epi : 5
Na/K/Cl 122/4,6
RBG 179 mg/dl


 Working Diagnosis

 CKD stage V cb Diabetic Kidney Disease with Metabolic
acidosis.
 CHF fc II LVH RVH synus rhytm cb ASHD
 Bronchopneumonia (HCAP)
 Mild anemia microcytic hypochrome cb chronic disease
 Type 2 DM controlled normoweigh
 Hyponatremia cb vomite

 Dd/
 CKD stage V cb Hypertension kidney disease with
metabolic acidosis
 CKD stage V cb GNC with metabolic acidosis
 Mild anemia microcytic hypochrome cb chronic bleeding
 Therapy

 Rest/ DD 1700 kkal Low protein 40gr Low salt II/O2 3L/1’
 IVFD EASPRIMER 500cc/24 h
 Inj. Ceftazidime 2x1 gr (IV)
 Inf. Levofloxacine 1x500 mg  2nd day 1x250 mg (IV)
 Correction of meylon 150 mEq in 200cc NacL 0,9% fast drip
 Correction of NacL 3% 12 h/colf (1 colf)
 Folic acid 1x5 mg (po)
 Bicnat 3x500 mg (po)
 Candesartan 1x8 mg (po)
 Simvastatin 1x20 mg (po)
 Fluid balance
 Planning

 Kidney USG
 Sputum culture
 Benzidine test