Sri Feliciani 030.08.

229

Category Name Age Address Job Religion Marital Status Ethnic Last education Admitted Ny. R

Description

50 years old Munjul Jaya 01/01 Malangsari Ibu Rumah Tangga Moeslem Married Sundanese Elementary school November 19 th 2012

 Patient

came to Karawang City Hospital with complaint of diarrhea since 2 weeks ago.

 Diarrhea

with blood and mucus Felt his body fatigue. Mild fever Decreased appetite

 Patient

comes with diarrhea since 2 weeks ago. she complained that she defecate 5-10 times a day. The feces is mixed with blood and mucus, also smell fishy. She also has fever, felt fatigue and decreased appetite. After defecating, patient felt pain in her stomach. She ignored nausea and vomitting.

hypertension (-) Liver disease (-)

Asthma (-)

Allergy (-)

Heart disease (-) Urinary stones (-)

Kidney disease (-) Diabetes mellitus (-)

Maag (-)

Alcohol consumption (-)

Injected drugs (-)

Smoking (-)
Traditional beverages (-)

Routine exercise (-)

Drink water as usual 8 glasses a day

2x a day eating, portion of rice a lot, often eat vegetables

Drinking tea everyday, coffe (-)

DM (-) HT (-) Neoplasm (-) Asthma (-) Have the same symptom (-)

General appearance

Moderately ill

consciousness

Compos mentis

Weight

54 kg

Height

160 cm

Nutritional state

BMI = 21,09 Normal

Blood preasure 110/80 mmHg

Heart rate 88x/m

Vital Sign
Temperature 36,5 C

Respiration 20x/m

Head Eyes

normocephali

Icteric sclera -/ Anemic conjunctiva +/+

Ears
Nose Mout h Neck

Hiperemic (-/-), tenderness (-/-), secret (-/-)

Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-), nostril breathing (-)

Red lip (+) dry (-). Carries (+) on M1 left and right. Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N) Limf node : enlargement (-), tenderness (-). Thyroid: enlargement (-), tenderness (-). JVP : 5 + 2 cm H2O

Lung Examination
Inspection: Symmetrical

Heart Examination
Inspection: Ictus cordis is available

Palpation: Equal vocal fremitus Percussion: toneless at ICS III-V sinistra Auscultation: Vesicular breath sound in both lung, ronchi -/-, and no wheezing

Palpation: Ictus cordis is palpable at 5th ICS LMCS Percussion :

Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS

Auscultation: Regular I II heart sound no murmur and gallop

Inspection
Brown skin, flat , symetrical, supple Caput medusae (-), spider nevi (-), icteric (-), ureum frost (-)

Auscultation

Bowel sound (+) ,venous hum (-), arterial bruit (-) Abdominal tenderness (-), pain present (-) at upper abdominal, liver and spleen inpalpable, undulation (-), mass palpable at left inguinal

Palpation

Percussion
Shifting dullnes (-) Pain of CVA (-)

Oedema

: : + +

+ +

Warm acrals

Deformation (-), brown skin , spider nevi (-), palmar erythema (-), pale (-), icteric (-), ureum frost (-)

Glomerulonephritis Urinary tract infections

Pneumonia CHF NYHA II e.c hypertension Pleuritis

CKD on HD stage V e.c Hypeertension

Suspect of KP & bilateral pleural effusion

Hematology (6-92012)
Hemoglobin Leukocytes

Result
10,2 gr/dL 31.900

Normal
12-17gr/dL 5.000 10.000

Trombocytes
Hematocrite Basophil Eosinophil Neutrophil Rod Neutrophil Segment

481. 000
33% 0 0 0 94

150.000 450.000
37-43% 0-1 % 1-3 % 2-6 % 40-70 %

Limphocytes
Monocytes

5
1

20-40 %
2-8 %

Urine Colour turbidity PH Proteine Reduction Ephitel Leukocyte Eritrosite Kalium Natrium Clorida

Result Yellow

Normal

Positive 0-5 /lpb 0-5 /lpb 2,7 140 102 3,5-5,6 mg/dl 134-145 mg/dl 100-110 mg/dl

GFR Rate : (140-age) x weight

72 x plasma creatinin = (140-37) x 70 72 x 20,29 = 4,94 mL/mnt/1,73m

History Thinking

Physical Examination

shortness since 4 months ago. Sometimes chestpain Cough sputum (yellow) his body fatigue and swelling in his legs. Urine like soap (foaming). Defecation black 1x and painless. History of HD 1x Nausea, fever often before to RS

Anemic sclera +/+ Bloated of abdomen Bowel sound (+) Oedema extremities (+)

Laboratory Finding Hemoglobin = 4,5 gr/dL Leukocytes = 12.200 Hematocrite =15% Eosinophil = 0

Proteine =+3 Reduction = +2 Leukocyte = 8-12 Eritrosite = 2-4 Turbid Ureum = 235,5 mg/dl Creatinine = 20,29 mg/dl

Neutrophil Rod = 0
Neutrophil Segment = 73

 CKD

on HD grade V e.c Hypertension Suspect of KP & bilateral pleural effusion

Non Pharmacology
1.PRC transfusion 2. Diet 3. Education: 1. Prepare for Hemodialysis 2. Life style

Pharmacology
IVFD NaCl 0,9 % (8 tpm) Transfusion PRC 2 unit Lasix 3x1 amp

Folat acid 3x1 CaCO3 3x1 Irbedox 1x150 mg

Ceftriaxone 2x1 inj

Ondancentron 3x8 mg

 ECG
Electrolyte BGA Lipid

Profile Biopsy