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PHYSICIAN INCHARGE
IA : dr. Jaja, dr. Yuni, dr. Fadhila
IB HCu : dr. Somarnam
IB CVCU : dr. GErry
IB ER : dr. Awan, dr. Nina
Chief : dr. Herwindo
Consultant : dr. Bogi, SpPD-KGEH
Social history: Patient work as farmer, married, have 2 children, never consume traditional potion,
he is a smoker with amount 2 bars/day
Family history: No one in his family has the same symptoms and/or disease like this.
Physical Examination
1
Lung Stem fremitus SS v v Rh - - Wh - -
D=S
SS v v - - - -
SS v v - - - -
Abdomen Soefl, epigastric pain (-),bowel sound normal, liver span 8 cm, traube space
is tymphanic, shifting dullness(-)
Extremities Leg edema (-),dry skin (-)
Laboratory Finding
2
Chloride 106 109 98-106 mmol/L
BGA
Urinalisis
Lab Value Lab Value
Colour Yellow 10 x
SG 1015 Epithelia +
PH 6.0 Cylinder -
Leucocyte +1 Hyaline -
Protein +2
Glucose negative
Erythrocyte 2+ 40 x
3
Eritrosit 10.5/hpf dismorfic
Urobilinogen - Crystal -
ECG:
C X R:
AP position, assymetric, enough inspiration, enough KV, bone and soft tissue normal, trachea in the
middle, diaphragma dextra dome shape, diaphragma sinistra covered by cardiac shadow, sinus
costophrenicus dextra and sinistra sharp, cor site normal, shape normal size CTR 56%
Conclusion : cardiomegaly
Abdominal USG:
- Chronic parenchimatous renal disease bilateral
- BPH grade II
Ct Scan:
- Verry large area Subdural hemmorage (fronto-temporo-parietal) sinistra with tight 2,2cm
and midline shift to the right
- Cerebri oedema
4
Cue Clue PL I.Dx P.Dx P.Th/ P.Mo
Male 70 yo: 1. DOC 1.1 subdural Bed rest head -VS
Ax: hemorage up 30’ -Subjective
Decrease of Consult to
consciousness since few neurologic
hour before admission, surgery
was performed departement
hemodialise last night
PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm
CT Scan:
-Verry large area
Subdural hemmorage
(fronto-temporo-
parietal) sinistra with
tight 2,2cm and midline
shift to the right
-Cerebri oedema
Male 70 yo: 2. CKD 2.1 Ht Fluid diet 6x200cc VS
Ax stage 3 Nephrosclerosis Equal fluid Subjective
Had hypertension never 2.2 GNC balanced Urine production
routin control. Known Avoid Calcium Phospor
had kidney disease nephrotoxic drugs
since 1 day before Plan to
admission was Hemodialise
performed hemodialise elective
last night
PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm
Lab:
Ur: 78 32 mg/dL
Cr: 3.06 2.03 mg/dL
Abdominal USG
-Chronic
parenchimatous renal
disease bilateral
-BPH grade II
5
Male 70 yo: 3. 3.1 primary fundusc Plan to give oral -VS
Ax: Hipertensi 3.2 secondary opy antihypertensio -Subjective
Had hypertension on n if patient was
didn’t know when he stable
suffered this condition,
poorly control.
PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm
Male 70 yo: 4. anemia 4.1 chronic disease Blood Threat as above -VS
Ax: normochr 4.2 def EPO smear, -Subjective
Decrease of appetited om reticulos - DL/3 days
since 10 days ago. normocite ite
Had hypertension not r
routin control
Diagnose CKD yesterday
and was performed
hemodialise
PE:
Pale conjungtive (-)
Lab:
Hb:
MCV: 91.20
MCH: 29.80
Male 70 yo: 5. 5.1 PUD Inj -VS
Ax: dispepsia 5.2 Uremic Metoclopramid -Subjective
Decrease of appetied syndrom gastropathy 3 x 10 mg iv
10 days ago, nausea Inj Omeprazole
and vomit 1 times 1 x 40mg iv
PE:
Tenderness (-)
Lab:
Ur: 78 32 mg/dL
Cr: 3.06 2.03 mg/dL