CLINIC

TUTORIAL

KEPANITRAAN KLINIK
RSI SULTAN AGUNG

Patients Identity
Name
: Mrs. S
Age
: 51 y.o
Sex
: Female
Address
: Terboyo Wetan Rt.01/Rw.02
Genuk, Semarang.
MR number : 01.11.75.67
Room
: Baitul Izzah 1
Status
: JKN Non-PBI
Entry date
: july 31th 2015
Out date
: Agustus 04th 2015

History Taking
A patient has came to the
emergency department caused by she
has been black out. Her family
confirmed that she had a headache for
a couple days ago. This symptoms
completed with some nausea and
vomitting. When she awakened, she
also said that she often felt so weak

Medical History
Hypertension (+)
Diabetes Mellitus
(+)
Drug allergy (-)
Gastritis (-)

Familys Medical History

Same disease (-)

Hypertension (-)
Diabetes Mellitus (-)
Cardiac disease (-)

Social Economic History

Private Sector
Guaranteed by National Medical Insurance
JKN Non-PBI

Systemic Medical History Taking

General
: weak
Skin :itch(-),jaundice(-),pale(+), dry skin (+)
Head
:headache(+)
Eyes :blurredvision(-),red eyes(-)
Ears :hearingloss(-),ring(-),discharge(-)
Nose :epistaxis(-),discharge(-)
Mouth
:cyanosis(-), thrush(-),bleeding gums(-)
Throat
:painswallow(-), hoarseness(-)
Neck : enlargement ofthe gland(-)
Chest
:cough(-),sputum(-),blood(-) Dyspneau (-)
Cardiac
:chest pain(-),palpitation(-)
Digestive :Abdominal pain (-),naussea (+),vomit (+),
diarrhea(-)
Musculoskeletal : weak(-),rigid(-),back pain (-)
Extremity
: oedem extremity ( -/-)

Physical Examination
General
Awareness

: weakness
: composmentis

Vital Sign

BP =
Pulse
RR =
T
=

150/100 mmHg
= 80 x/menit
22 x/menit
36,5 0C

Status Present

Sex
Age
Weight
Height
BMI

:
:
:
:
:

Female
51 y.o
50 kg
155 cm
20,83(normoweight)

general

Weakness

skin

Ikterik (-)

head

mesocephal

Eyes

Red eye (-), conjunctiva anemis (-/-),

sclera icteric (-/-), exoftalmus (-)

ear

discharge (-)

nose

epistaxis (-), discharge(-)

mouth

sianosis (-) ,bleeding gums (-), stomatitis

(-), pain swallow (-), pharinx hiperemis (-)

neck

Thyroid enlargement (-)

Cardiovascula
r

Palpitation (-)

respiratory

Dyspneu (-)

gastrointestin
al

Abdominal pain (-), nausea (+), vomiting

(+), diarrhea (-)

muskuloskelet Weakness (-) , atrofi (-), tremors (-)

al
Central

(-)

THORAX - PULMO
INSPEKSI
STATIC

DINAMYC

ANTERIOR
RR : 22x/min,
Hyperpigmentation (-), tumor (-),
inflammation (-), spider nevi (-),
Hemithorax D=S, ICS Normal,
Diameter AP < LL
The movement of hemitorax
D=S, abdominothorakal
breathing (-), muscle retraction
of breathing (-), retraction ICS (-)

POSTERIOR
RR : 22x/min,
Hiperpigmentasi (-), tumor (-),
inflammation (-), spider nevi (-),
Hemithorax D=S, ICS Normal,
Diameter AP < LL
The movement of hemitorax
D=S, abdominothorakal
breathing (-), muscle retraction of
breathing (-), retraction ICS (-)

Palpation pain (-), tumor (-),

enlargement of ICS (-),
Stem fremitus D=S

Palpation pain (-), tumor (-),

enlargement of ICS (-),
Sterm fremitus D=S

Sonor +/+

Sonor +/+

ronchi (-) , wheezing (-) ,

vesikuler (+) D=S

ronchi (-) , wheezing (-) ,

vesikuler (+) D=S

PALPATION

PERCUTION

AUSCULTATION

THORAX - COR

INSPECTION
Unseen Ictus Cordis
PALPATION
Ictus cordis is palpable at ICS V, 2 cm lateraly from left mid
clavicula line, thrill (-)
PERCUTION
Upper borderline
Waist

:
:
:
:

ICS
ICS
ICS
ICS

Lower right
borderline
Lower left
borderline
AUSCULTATION
S1 & S2 (+), Additional sound (-),

II left sternal line

III left parasternal line
V right parasternal line
V front axilla line

Abdomen
1.Inspection

convex of surface(+), sycatric(-), striae(-),

enlargement of vena (-), caput medusa (-)

2.Auskultasi

peristaltic (12x/minutes), aorta abdominal bruit

(-), A. Lienalis, A. femoralis (-)
tympanic all abdominal surface,
Liver span : dex = 12cm ; sinistra = 6cm, area
troube (+)
mass (-), pain (-) , hepatomegali (-),
Spleenomegali (-) Murphys sign (-)

3. percussion
4. palpation

Extremity
Ekstremity

Superior

Inferior

Oedem

-/-

-/-

Cold extremities
Physiological
Reflect
Ikteric

-/-

-/-

+/+

+/+

-/-

-/-

Impression

Normal

Laboratory Examination
Result

unit

Normal Value

Haemoglobin

8,1

g/dl

11,5 15,5

Hematocrite

25,5

33 45

Leukocyte

12,9

thousand/uL

3,6 11,0

Platelet

436

thousand/uL

150 440

Blood type / Rh

A/+

result

value

Blood Sugar

176 mg/dl

75-110 mg/dl

Quality HBsAg

Non-reactive

Non-reactive

Result

Normal Value

Blood
Chemical
57 mg/dl H

10-50 g/dl

Blood Creatinin

3,54 mg/dl H

0,5-0,9 mg/dl

Natrium

136,3 mmol/L

135-147 mmol/L

Kalium

4,73 mmol/L

3,5-5 mmol/L

114,9 mmol/L H

95-105 mmol/L

Ureum

Chloride

Abnormality Data

History Taking :
Nausea
Vomiting
Headache
Weakness
Pale

Physical
Examination:
Dry Skin
Pale

Laboratoric
Examination:
1. Low Hb 8,4
2. Low Ht
3. High Ureum
4. High Creatinin
5. High Chloride

PROBLEM LIST
1. Chronic Kidney Disease

Chronic Kidney Disease

Ass: 3rd Grade CKD

IP Dx : Ureum, Creatinin, Blood Test, Electrolite (Na, K),
Kidney Function Test
Ip Rx :
Non Pharmacologic
Low Protein Consumption
Pharmacologic
R/ Amlodipin 5mg
1x1
R/ Valsartan 80 mg
1x1
R/ Ondancetron 4mg
3x1
R/ Omeprazol
2x1

R/ Renal Protector
2x1
IP.Mx : Blood Test, Ureum, Creatinin

Calories needed
IW = (155 100)-10%.50 = 50 ( weight 50
normo)
50x 25 = 1250 kal / day
Age > 40 = -5%
Activity mild = +10%
Metabolic stress = 20%
TOTAL = 1250 + (25%.1250) = 1250 +
312,5 = 1562,5

Patient with DM & CKD

1562,5 breakfast 25%, lunch 30%,

dinner 25%, snacks between 2 big meals
10%. All portion of dishes must contain
less percentage of proteins about 35g a
day, less kalium, less phospat, and drink
limitation using last day urinating + IWL
(500cc)
Conclusion :
Carbo 60%, protein (35g), fat (20%), no
fruits, no milk, no cocoa,

TERIMA
KASIH