Congestive Heart Failure with Acute Kidney Injury

Dessy Esa S030.08.074

Identity

Name : Mr. UAge : 49 yearsGender : MenAdress : Dusun Krajan, Kec. Cimalaya, KarawangOccupation : LaborReligion : MoslemMarital status : MarriedRace : SundaneseEducation : Elementary school

Admisson to hospital at Oct, 22th 2012

ANAMNESEAutoanamnese on Oct 22th 2012 at 8 pm

Main complain

Shortness of breath

History of present disease

History of past disease

Family history No one in his family got a

symptom or disease like him

Hypertension (-), Maag (-), Liver disease (-), Kidney disease (-), Cancer (-), Diabetes Mellitus (-)

Habitual history

• Patient quits smoke since he got sick. He’s not an alcoholic and never use herbal therapy.

• He eats 2-3x times a day• Rarely do the exercise

Picture of patient

General condition

THORAX HEART

Inspection : Symmetrical Palpation : Equal vocal resonancePercussion : Sonor in both lungsAuscultation : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)

THORAXLUNG

INSPECTION brown skin, symetrical, supple, flat Icteric (-), Caput medusae (-), spider nevi (-)

AUSCULTATION Bowel sound (+) , venous hum (-), arterial bruit (-)

PERCUSSION Shifting dullnes (-)

PALPATION Hepatomegali (+)right lobe enlarges 6 cm b.a.c

left lobe enlarges 8 cm below processus xyphoideus Splenomegali (-) Tenderness (+) bowel sound(+)

ABDOMEN

Warm acral

Edema

Deformation (-), brown skin , spider nevi (-), palmar erythema (-), pale (-), icteric (-), flapping tremor (-), sweeling on both knee and painfull

EXTREMITY

Laboratory testOct 22th,2012

test hasil Nilai normal

Hematologi

Hemoglobin 12,1 (12-17)%

Leukocytes 16.900 (5rb-10rb)

Trombocytes 382.000 (150-450)rb

Hematocrite 37 (37-48)%

Kimia darah

GDS/reduksi 41 (80-140)

Ureum 50,1 (10-45)mg/dl

Creatinin 1,88 (0,4-1,5)mg/dl

SGOT 28 (<40)

SGPT 23 (<40)

Laboratory testOct 23th, 2012

Test hasil Nilai normal

Hematologi

Hemoglobin 12,0 (12-17)g%

Leukocytes 4.600 (5.000-10.000)

Trombocytes 174.000 (150-450)rb

Hematocrite 36 (37-48)%

Kimia darah

GDS/ Reduksi 104 (80-140)mg/dl

Ureum 146,2 (10-45)mgldl

Creatinin 2,71 (0,4-1,5)mg/dl

Laboratory testOct 24th, 2012

test hasil Nilai normal

Ureum 129,9 (10-45)mg/dl

creatinin 2,48 (0,4-1,5)mg/dl

Rontgen Thorax

• CTR > 50%• Enlargement of

Left Ventricle• Enlargement of

Right Ventricle• Enlargement of

Left Atrium

Electrocardiogram

Echocardiogram

resume

Differential Diagnoses

Working diagnose

Congestive Heart Failure et Causa Coronary Heart Disease and

Hypertension Heart Disease with Acute Kidney Injury.

Suggested examination

therapy

prognosis