CASE 1hipertensi Anna

8/2/2019 CASE 1hipertensi Anna

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Name / sex / ageName / sex / age

::

MrMr. H. H,, MMale,ale, 4343 yyoo

AddressAddress ::

Wadas CikampekWadas Cikampek

ReligionReligion : Islam: Islam Marital statusMarital status ::

MarriedMarried

OccupationOccupation ::

meatball sellermeatball seller

Date of admissionDate of admission ::

1414thth JJanuaryanuary 20120111


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Auto anamnesisAuto anamnesis was taken awas taken att RSUDRSUDKarawang onKarawang on 1717thth JJanuaryanuary 20120111

Chief complaint :Chief comp

laint :

The patient has been havingThe patient has been having severesevereheadacheheadache forfor 11 weekweekbefore admitting tobefore admitting to

the Emergency unit of RSUD Karawang.the Emergency unit of RSUD Karawang.

Additional Complaint :Additional Comp

laint :DDizziness, nausea, chest pain andizziness, nausea, chest pain and

shortness of breath.shortness of breath.


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The patient has been havingThe patient has been having severesevereheadacheheadache forfor 11 weekweek before admittingbefore admittingto the Emergency unit of RSUDto the Emergency unit of RSUDKarawang. The pain is throbbing, occursKarawang. The pain is throbbing, occurs

in spasms, and is felt at the back or topin spasms, and is felt at the back or topof the headof the head,, It suddenly appears, andIt suddenly appears, anddisappear if he lied down.disappear if he lied down.

The patient has been having painThe patient has been having pain

in her chest for 3 daysin her chest for 3 days.. The painThe painsuddenly appears and spread to hsuddenly appears and spread to hisisback. It took less than 10 minutes andback. It took less than 10 minutes andrelieved by rest.relieved by rest.


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SometimesSometimes hhe feels shortness ofe feels shortness ofbreath if he was doing hard activities.breath if he was doing hard activities.

Patient also complained ofPatient also complained ofnausea. But not continue withnausea. But not continue withvomiting.vomiting.

Patient declined oh having coughPatient declined oh having coughand excessive exercise.and excessive exercise.

The patient declined of having anyThe patient declined of having anyabnormalities of his urination andabnormalities of his urination and

defecation.defecation.HHe said thate said that hhe had been using antie had been using anti

hypertension drugs for a long time.hypertension drugs for a long time.


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The patient admitted of having the similarThe patient admitted of having the similar

condition previously in hcondition previously in hisis life forlife for fivefiveyearsyears

The patient decline of having diabetesThe patient decline of having diabetes

mellitus and any kind of disease of themellitus and any kind of disease of theheart, lung, and liver.heart, lung, and liver.

The patient decline of having allergy toThe patient decline of having allergy to

certain food or drug.certain food or drug.The patient decline of having history ofThe patient decline of having history of

serious disease or condition that makeserious disease or condition that make

him hospitalize.him hospitalize.


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The patient said that hThe patient said that hisis daughterdaughter and hisand his

fatherfather also have the same disease that healso have the same disease that he

sufferssuffers

The patient decline of having family withThe patient decline of having family with

diabetes mellitus and any kind of diseasediabetes mellitus and any kind of disease

of heart, lung and liver.of heart, lung and liver.

The patient decline of having family withThe patient decline of having family with

allergy to any kind of subject.allergy to any kind of subject.


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The patient stated that :The patient stated that :

HHe does not smokee does not smoke

HHe does not consume alcohole does not consume alcohol HHe has enough sleep time per daye has enough sleep time per day

He eat 3 time per day and also drinkHe eat 3 time per day and also drink

coffeecoffee HHe doesnt do physical exercise regularlye doesnt do physical exercise regularly


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General ConditionGeneral Condition : Moderately ill: Moderately ill

ConsciousnessConsciousness : Compos Mentis: Compos Mentis

BMIBMIweight : 73 kgweight : 73 kg

heigh : 170 cmheigh : 170 cm

BMI : 25, 4 (overweight)BMI : 25, 4 (overweight)


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Vital SignVital Sign Blood PressureBlood Pressure :: 180180/ 1/ 1110 mmHg0 mmHg

Pulse RatePulse Rate : 96 times / minute: 96 times / minute

TemperatureTemperature : 36,5: 36,500 CelsiusCelsius

Breath RateBreath Rate : 2: 288 times / minutetimes / minute


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HeadHead : Normocephali: Normocephali

EyesEyes ::

Anemic conjunctivae (-) / (-)Anemic conjunctivae (-) / (-) Icteric Sclera (-) / (-)Icteric Sclera (-) / (-)

JVPJVP : normal: normal

Lymph gland is not palpableLymph gland is not palpable Thyroid gland is not palpableThyroid gland is not palpable


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InspectionInspection : flat: flatPalpationPalpation

No pain present on palpation at all abdominalNo pain present on palpation at all abdominal

regionregion No liver and spleen enlargementNo liver and spleen enlargement

PercussionPercussion No pain present on abdominal percussionNo pain present on abdominal percussion Sounds tympaniSounds tympani

AuscultationAuscultation Normal bowel soundNormal bowel sound


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No cold and cyanotic extremityNo cold and cyanotic extremity

No edema is found in all extremitiesNo edema is found in all extremities


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Test Result Normal LevelHemoglobin 13 gram % 12 - 17 gram %

Leukocyte 6.100 5000 10000

Thrombocyte 232.000 150.000 - 450.000

Hematocryte 41 % 37 48 %

The test was taken on 16th January

2011

GDS 109 mg/dl 80 140 mg/dl

Ureum 44,2 mg/dl 10 45 mg/dl

Creatinine 0,73 mg/dl 0,4 1,5 mg/dlNatrium 142 mmol/L 134 145 mmol/L

Kalium 3,8 mmol/L 3,5 5,6 mmol/L


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ECGECG normalnormal


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Headache, suddenly appears, and disappear if heHeadache, suddenly appears, and disappear if he

lied down.lied down. Pain in chest for 3 days suddenly appears andPain in chest for 3 days suddenly appears and

spread to hspread to hisis back.back. Shortness of breath if he was doing hard activitieShortness of breath if he was doing hard activitiess

Nausea, not continue with vomitingNausea, not continue with vomiting had been using anti hypertension drugs for a longhad been using anti hypertension drugs for a long

timetime admitted of having the similar condition previously inadmitted of having the similar condition previously in

hhisis life forlife for fivefive yearsyears hhisis daughter and fatherdaughter and father also have the same diseasealso have the same disease

that he suffersthat he suffers Blood PressureBlood Pressure : 1: 18080 / 1/ 1110 mmHg0 mmHg


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Differential diagnosisDifferential diagnosis

1.1. Hypertension grade IIHypertension grade II

2.2. Left Heart FailureLeft Heart Failure

3.3.Angina PectorisAngina Pectoris

4.4. Myocardial infarctionMyocardial infarction

Working diagnosisWorking diagnosis

Hypertension Grade IIHypertension Grade II


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Working diagnosisWorking diagnosis

Hypertension Grade IIHypertension Grade II

Kategori Sistolik DiastolikNormal


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Laboratory : Renal functionLaboratory : Renal function

Rontgen thoraxRontgen thorax

Cardiac enzymeCardiac enzyme


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Non medikamentosaNon medikamentosa Educate patients about their illness,Educate patients about their illness,

particularly by reassuring them that theparticularly by reassuring them that the

illness is a serious threat to theirillness is a serious threat to their

physical health and need drugs for a lifephysical health and need drugs for a life

timetime

Lifestyle modificationLifestyle modification


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MedikamentosaMedikamentosa

1.1. Captopril 25 mg 2x1Captopril 25 mg 2x1

2.2. HCT 25 mg 1x1HCT 25 mg 1x1


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Quo ad vitamQuo ad vitamDubia ad bonamDubia ad bonam

Quo ad functionamQuo ad functionamDubia aDubia add malammalam

Quo ad sanationamQuo ad sanationamAAdd malammalam


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CASE 1hipertensi Anna

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