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    Morning Suwarti CKD HT

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    Jongga Siahaan
    The document describes a 46-year-old female patient presenting with increasing breathlessness over the past month. Her history includes hypertension, CKD on hemodialysis, and ascites. On examination, she has severe general appearance, enlarged abdomen, pretibial edema, and hepatomegaly. Laboratory tests show anemia. The working diagnoses are emergency hypertension, CKD, CHF, and massive ascites. Treatment includes oxygen, IV fluids, antihypertensives, and a plan for further tests and hemodialysis.

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    Morning Suwarti CKD HT

    Uploaded by

    Jongga Siahaan
    13 views12 pages
    The document describes a 46-year-old female patient presenting with increasing breathlessness over the past month. Her history includes hypertension, CKD on hemodialysis, and ascites. On examination, she has severe general appearance, enlarged abdomen, pretibial edema, and hepatomegaly. Laboratory tests show anemia. The working diagnoses are emergency hypertension, CKD, CHF, and massive ascites. Treatment includes oxygen, IV fluids, antihypertensives, and a plan for further tests and hemodialysis.

    Original Description:

    CKD HT

    Original Title

    Morning Suwarti ckd ht

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    The document describes a 46-year-old female patient presenting with increasing breathlessness over the past month. Her history includes hypertension, CKD on hemodialysis, and ascites. On examination, she has severe general appearance, enlarged abdomen, pretibial edema, and hepatomegaly. Laboratory tests show anemia. The working diagnoses are emergency hypertension, CKD, CHF, and massive ascites. Treatment includes oxygen, IV fluids, antihypertensives, and a plan for further tests and hemodialysis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    13 views12 pages

    Morning Suwarti CKD HT

    Uploaded by

    Jongga Siahaan
    The document describes a 46-year-old female patient presenting with increasing breathlessness over the past month. Her history includes hypertension, CKD on hemodialysis, and ascites. On examination, she has severe general appearance, enlarged abdomen, pretibial edema, and hepatomegaly. Laboratory tests show anemia. The working diagnoses are emergency hypertension, CKD, CHF, and massive ascites. Treatment includes oxygen, IV fluids, antihypertensives, and a plan for further tests and hemodialysis.

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    Suwarti Ningsih/female/ 46-yo/HCU neuro

    Chief Complaint:

    • Breathlessness increasing since 1 day ago

    Present Illness History

    • Breathlessness increasing since 1 day ago. Breathless have


    been felt since 1 month ago, breathless influenced by mild
    activity like walk a few step, sleeping with 2 pillows under
    head (+), wake up at midnight caused by breathless (+)
    • There is no fever, no cough
    • The patient felt the stomach getting bigger since 1 month ago
    • Weakness and fatigue since 1 week ago, there is no bleeding
    • The patient not urinating for 3 years, the patient is known to
    have CKD cb hypertension renal disease on HD, regular HD
    Monday and Thursday since 7 years ago in Dharmasraya
    Hospital
    Past illness history

    • History of hypertension (+)


    • History of DM (-)

    Family illness history

    • No family members suffer from the


    same disease
    Physical Examination
    VII

    • General Appearance : Severe

    • Consciousness level: CMC

    • BP : 200/110 mmHg

    • HR : 89x/minute

    • RR : 26x/minute

    • T : 36.7 º C

    • SpO2 : 99%
    • Eye VII
    – conjunctiva anemic (+), icteric sclera (-)
    • Neck
    – JVP 5-2 cmH20
    • Lung:
    – Inspection: statically & dynamically symmetric
    – Palpation: fremitus tactile right = left normal
    – Percussion: sonor
    – Auscultation: vesicular, Rh -/- Wh -/-
    • Cor:
    – Inspection: ictus cordis is not seen
    – Palpation: ictus is palpated at 2 finger lateral LMCS ICS V
    • Percussion: Left border: 2 finger lateral LMCS ICS V
    • Right border: linea sternalis dextra ics IV
    • Upper border: linaa parasternalis ICS II
    – Auscultation: regular, murmur (-) gallop (-)
    • Abdomen: VII
    – Inspection: enlargement (+)
    – Palpation: hepatomegaly (-) splenomegaly (-)
    tenderness (-), undulation (+)
    – Percussion: tympani
    – Auscultation: bowel sound (+) N

    • Extremities:
    – Oedema pretibia +/+
    – Physiologic Reflex +/+
    – Pathologic Reflex -/-
    Laboratory
    Items Value
    VII
    Hb 8.0 gr/dl

    Ht 25 %

    Leukosit 7.880 /mm3

    Platelet 281.000/mm3

    Na/K/Cl 140/5.1/108

    Ur/Cr 62/7,9

    AGD 7,41/35/131/22.2/-2.0/99
    ECG
    VII
    Thorax
    VII
    Problems

    Breathlessness
    Ascites
    Working Diagnosis

    Emergency Hypertension
    Chronic Kidney Disease stage V cb hypertension renal disease on
    Haemodyalisis
    CHF NYHA fc III SR cb Hypertension Heart Disease
    Massive Ascites cb CKD
    Mild Anemia normocytic normochrome cb chronic disease
    Therapy

    • Rest/Diet ML DH Low Salt Low Protein 48 gr


    • O2 5 lpm NC
    • IVFD Renxamin 200cc/24jam
    • Drip nicardipine 1 amp on 46 cc NaCl 0,9% via syringe pump , up titration
    • Amlodipin 1 x 10 mg
    • Candesartan 1 x 16 mg
    • Clonidin 3 x 0,15 mg
    • Folic acid 1 x 5 mg
    • Sodium bicarbonate 3 x 500 mg
    Plan

    Check complete peripheral blood


    Check PT, APTT, SGOT, SGPT, Albumin, Globulin,
    Hepatitis Marker, HIV marker
    USG Abdomen
    Tapping ascites
    echocardiographyv
    Haemodyalisis

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