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29 NOVEMBER 2014
BY: Wan Adi Surya and Elita Riyu
Summary of
Data Base
Ny.
Jumain/M/43yo
/W27
Chief
complaint:
SOB and
Weakness
Patient
suffered from
shortness of
breath since 1
weeks before
admision, but
after doing
hhaemodialysis
, shortness of
breath is
decreased.
Patient is
scheduled to do
HD once a
week. Its
patient 3rd
schedule for
HD. Since 2
days before
admisions,
pasien suffered
form weakness,
lossing of
Physical Examination
Vital Sign:
GCS 456
BP: 90/60 mmHg
HR: 88 bpm, reguler
RR: 24x/m
T.ax: 35,7 C
General appearance:
Looked Moderatelly Ill
Compos Mentis
Head:
Pale conjungticva (-/-)
Ikteric sclera (-/-)
Neck:
JVP R+2cm H2O
Lymphnode enlargement (-)
Inserted double-lumen cath.
Thoraks:
Heart:
Ictus invicible, palpable at ICS
6 2cm lateral MCL S,
LHM~Ictus, RHM~ SL D, S1S2
single bising sistolik gr. 4/6
LPS ictus
Lung:
Spontan Symetrically
breathing, Stem Fremitus
D=S,
Vesicular breath sound,
Rhonchi (+) basal, Wheezing ()
Laboratory Findings
(30/11/2014)
Na: 123
K: 7,16
Cl: 98
(30/11/2014)
Hb: 6,80
RBC: 2,36
WBC: 15.850
HCT: 20,50
PLT: 304000
MCV: 86,90
MCH: 28,80
Diff Count:
2,7/0,1/87,6/2,8/6,8
GDS: 99
Ur/Cr: 400,20/29,3
Uric acid: 13,7
OT/PT: 18/9
Albumin: 3,04
Ca: 5,0
Ph: 17,4
Chol.total: 109
TG: 145
HDL: 21
LDL:54
HbsAg: Negatif
Anti HCV: Negatif
Problem List
1. SOB
Initial Diagnosis
1.1 Uremic lung
1.2 HC st.C fc.3
PDx
CXR photo
Blood Gas Artery
(BGA)
Electro
Cardiography
Cardiac marker
PTx
O2 2-4 lpm NC
Soft kidney diet
1900 kkal, protein
0,6-0,8g/kgBB/day
PO:
NaBic 3x500 mg
CaC03 3x100 mg
Pmo
Subjective, VS
Urine production
Continue HD as
scheduled
2.1 HT
nephrosclerotic
USG Abdomen
O2 2-4 lpm NC
Soft kidney diet
1900 kkal, protein
0,6-0,8g/kgBB/day
PO:
NaBic 3x500 mg
CaC03 3x100 mg
Continue HD as
scheduled
Subjective, VS,
Urine production
appetite,
nausea (+), but
no vomitting,
feeling of
fullness. Patient
is diagnosed
with HT since 3
years ago and
consume
captopril as
antihypertentio
n. DM istory
was denied.
Patient is a
married man
with 3 children,
works as a
driver. Patient
smoke arround
2 pack a day,
and theres
history of jamujamuan dinking
Abdomen:
Flat, soefl, BS(+)normal,
Traube space typanic, Liver
span 8cm
Extrimities:
Warm extrimities, Edema (-)
3. Shock condition
Drip NE 1amp in
100cc NS, starts
from 4 dpm, add on
4 dpm/15minute up
to MAP>70 then
maintenance
Subjective, VS,
urine production
4. Dyspepsia syndrome
4.1 Uremic
gastropathy
4.2 PUD
Inj:
Metoclopramide
3x10 mg intravena
Subjective, VS,
Male, 43 yo
Ax: general
weakness
PE: Pale conjungtiva
Lab findings:
Hb: 6,8 gr/dL
MCV: 86,9 fL
MCH: 28,8 pg
MCHC: 31,30 g/Dl
5.Anemia NN
PO:
Omeprazole 2x20
mg
Amlodipin 1x12 mg
Blood smear
Confirmed
diagnosis
Epo transfusion is
planned
Sujective, VS