Meydiani, 53yo, HCU 02

• CC:
Breathlessness increased since 1 day ago
• Present Illness History:
– Breathlessness increased since 1 day before
hospitalized, has been felt since 2 months ago,
influence by activity, not influenced by food or weather
– Fever (+) since 2 days ago, not high, no chill, no sweet.
– Cough (+) since 2 days ago sputum (+) blood (-)
– swollen at lower ekstremities since 2 weeks ago, no
pain, no reddish.
– history of bleeding (-)
– patient has been known as CKD stage V and routine
Hemodylise 2 times/ weeks since 2 weeks ago and DM
type II since 5 years ago.
 Past Illness History
 History of DM (+) since 5 years ago
 histoey of hypertension since 1 years ago

Family Illness History

No Family had symptoms like this patient.
 Physical Examination
 Consciousness level : CMC
 BP : 180/100 mmHg
 HR : 85x/minute
 RR : 32x/minute
 T : 37,4 °C
Eye
 Conjunctiva anemic (+)
 Sclera icteric (-)
Neck
 JVP 5+1 cmH20
 Lymph enlargement (-)
Ear : deformity (-)
Nose : deformity (-)
Mouth : caries (-)
• Lung :
 Inspection : both symmetric at static and dinamic
 Palpation : fremitus right = left
 Percussion : sonor right = left
 Auscultation : bronchovesicular, Rh +/+, whz +/+
 Cor :
 Inspection : ictus was seen 1 finger at lateral LMCS RIC VI
 Palpation : ictus was palpated 1 finger at lateral LMCS RIC VI
 Percussion :
Left Border : 1 finger at lateral LMCS RIC V
Right border : LSD
Upper border : RIC II
 Auscultation : sinus rhythm, murmur (-)
• Abdomen :
 Inspection : enlargement (+)
 Palpation : liver and lien not palpable
 Percussion : shifyhing dullness (+), tymphany
 Auscultation : bowel sound (+) normal
 Back
 CVA tenderness (-)
• Extremities :
 Oedem +/+
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Laboratory
Hb 9,8
WBC 15.850
Platelet 225.000
Haematocrit 31%
Ureum/creatinin 65/ 4,8
Na/K/Cl 137/4,1/107
RBG 266
PH 7.44
PCO2 31,1
PO2 66,1
HCO3 21,4
BEecF -1,5
SO2 92,8 %
ECG
Chest x ray
 Working Diagnosis

 septic ec HAP with hypoxemia

 Acute Lung Oedem
 CKD Stage V cb nefrosclerosis diabetic on HD
 DM Type II uncontrolled overweight
 mild anemia microcitic hypochrom cb chronic
disease
 Therapy
 Rest/low salt low protein 48 gr 2100 Kkal / 02 10l/minutes (NRM)
 IVFD Easprimer 24 hours/kolf
 drip lasix 5 ampul in syiringe pump, dosage 5 mg/hours
 Drip insulin 50 unit with 50 cc NaCl 0,9% - protocol critical ill start
with 2,5 mg/hours, titrated.
 Inj ceftazidime 2x1gr
 Inf. Levofloxacin 1 x 750 mg day 1 continued inf. Levofloxacin 1 x
250
 inj fluimucyl 3x1 amp
 nebu farbivent/8 hours
 Amblodipin 1 x 10 mg
 Candesartan 1 x 16 mg
 Folic acid 1 x 5 mg
 Bicnat 3 x 500 mg
 paracetamol 3x500 mg
 Fluid balance
• Hemodialisa
• Culture Sputum
• Exp. Ro thorax