DUTY REPORT DESEMBER 16TH 2013

ELVA NORA,FEMALE, 29 YO ( FW )
Cc : Epigastric pain since 3 days ago Present illness history : Epigastric pain since 3 days ago, not continue, no referred pain, pain can not be appointed by the finger, pain is reduce when food is filled Nausea since 3 day ago, not vomitestomach fells bloated and suffocating since 3 days ago Fever since 3 days ago, not continue, tremble (-), sweat (-) Diarrhea since 3 days ago, frequency 10 times/day,mucous (+),bloody stool (+) Decreased of apetite since 2 days ago Pale and fatique since 2 days ago Dizziness since 2 days ago Breathlesness (-), cough (-) Bloody urination and sandy were denied History of Hypertension (+) since 2 months ago

Patients has been knew suffer neprothic syndrome since 2 months ago, and get metilprednisolon (24-4-4)mg,captopril 3 x 12,5mg, simvastain 1x20 mg

Physical examination : Consc : CMC BP : 130/80 mmHg weight= 43kg HR : 120x/ Height= 157cm RR : 20x/ IMT= 20 T : 38,8 C Eye : Edema palpebra, Conjuctiva anemic,sclera not icterus Mouth : Candidiasis (-) Neck : JVP=5-2cmH2O Lung : vesikuler, rales (-/-), Whezzing (-/-) Heart : ictus was palpable 1 finger medial of LMCS RIC V Abdomen: Liver palpale 2 finger bac, 2 finger bpx, blunt edge, flate surface, rubbery consistance, pain (-), Sleen unpalpaple Ext : Fisiology reflex :(+)/(+) Normal Pathology reflex:(-)/(-) Normal

LABORATORIUM
Hb Leu Ht Trombosit Na K Cl GDS Ureum Creatinin Protein urin : 9,7 gr/dl : 1200/mm3 : 28% : 70.000/mm3 : 111 mmol/L : 3,9 mmol/L : 83 mmol/L : 192 mg/dl : 60 mg/dl : 1,7 mg/dl : (+++)

WD/ - Gastropathy steroid - Neprothic syndrome on therapy - Hyponatremia ec low intake - AKI RIFLE I ec prerenal ec dehydration - Pansitopenia ec hypoplasia

DD/ Peptic ulcer ec steroid

Th : Rest/Gastric Diet II/Neprothic syndrome Diet IVFD NaCl 3 % 12 hours/kolf Metilprednisolon (24-4-4)mg Lansoprazole 1x30mg Simvastatin 1x20 mg Captopril 2x62,5 mg Osteocal 1x1 Paracetamol 3x500mg Fluid Balance

SUGGESTION EXAMINATION
Liver FunctionTest Renal Function Test Esbach Complete blood count Gastroscopy