1.
1. yasmaniar, 61 yo, female, FW 15
• CC :
• Breathlessness since 5 days ago.
• Present illness and history
• Breathlessness since 5 days ago. it has been felt since 1 week ago.
breathlessness affected by activity, it’s not affected by food or
weather. History of of sleep with higher pillow.
• Weakness and tired since 1 week ago
• Fever since 1 week ago, fever goes away, not accompanied by chills
and sweating.
• Swelling in both extremities since 2 weeks ago.
• Cough with phlegm since 2 weeks ago,
• Decrease of weight is denied.

2.
• There is no nause and vomiting
• The patien has been diagnosed with CKD stage
V on HD since 4 months ago. The patient has
history heart failure since 4 months ago. And
never goes to control
• The result of ecocardiograpy at global systolic
function LV : good; EF 60%;
• defecation normal in color and consitency.
• Decrease of urination since 4 months ago.

3.
Patient illness history
• History of DM (-)
• History of HT (+) since 5 years ago
• Family History
- History of with hypertension (+)

4.
Physical examination
• Conciusness level : CMC
• Bp : 159/95 mmHg
• HR : 102 /minute
• RR : 27x/minute
• T : 38,7
• Sao2 : 98-99% with nasal canul 5 lpm

5.
• Eye
– Conjunctiva anemis +
– Sklera icteric –
– Neck :
JVP : 5 ± 3 cmH2O

6.
• Lung
– Inpection : simetric at static and dinamic
– Palpation : vokal fremitus decreased at right lung
– Percusion : dull at right lung below RIC 7
– Auscultation : bronkovesikuler breath sound
decreased at lower left lung, rales +/+,wheezing -
/-

7.
• Cor :
- Inpection :ictus wasn’t seen
- Palpation: ictus was palpated at finger 2
lateral LMCS ICS VI
- Percusiion : Cardiomegali +
- Auscultation : regular rhytm, gallop (-),
murmur (-)

8.
abdomen
- Inpection : enlargement (-)
- Palpation: hepar and lien aren’t palpable
- Percusiion : tympani
- Auscultation : bowel sound (+)
- Extremity : pitting edeme +/+

9.
Hb/ht/leu/trom 8.0/24/16.190/279.000
DC 0/0/74/18/8
Alb/Glo 2,7/3,3
Ur/cr 8/4,8
GDS 186
SGOT/SGPT 15/33
PT/APTT/Ddimer 11,7/31,4/95
Na/K/CL/Ca 134/3,6/96/8,7
AGD 7,45/41/16190/279.000

10.
Blood Smear

11.
Urin

12.
CXR

13.
ECG

14.
Working diagnosis
• CKD stage V on HD cb Hypertension kidney
Disease
• HAP
• Mild Anemic Normositik normokrom cb
chronik disease
• CHF NYHA fc class III
• Pleural effusion dextra

15.
therapy
• Rest/ liquid food Low Salt low protein 48 gr / o2 5
lpm per nasal
• IVFD easprimmer 250 cc/ 24 hour
• Inj cefepime 3x2gr
• Inj levovloksasin 1x750 mg (iv) 1x250 mg (iv)
• Asetilsistein 3x 200mg
• Natrium bicarbonat 3c500mg
• Asam folat 1x 5mg
• Candesartan 1x8mg

16.
Differensial diagnosis
• Lung tuberculosis

17.
plan
• Usg thorak
• Usg abdomen
• Kultur sputum
• Gene expert