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 I WM/ M / 52 YO, Br Kesiman – Denpasar Timur

 CC : Weakness

 Patients complain of weakness since 2 weeks ago, before the patient


complained of nausea and vomiting every meal and drink and patients
also complain decrease of appetite. Patients also complain of coughing
with phlegm is white. Bloody cough were denied. Complain of weight loss
and night sweating were denied. Pasien also complained wound on the
left leg since 2 weeks ago. The longer the wound is getting bigger so it is
difficult for the patient to walk and doing the activity. Bowel movements
were normal but since one week ago the patient complained of the
amount of urine is reduced by the total amount of urine approximately
400-500cc every day.

 PAST MEDICAL HISTORY

History of DM (+) since 13 years ago and taking medication with Glikuidon
30mg OD and Metformin 500mg TID. History of Lung TB since 3 years ago
with Rotgen and BTA (+) and complit treatment in Wangaya Hospital. HT
(-), Heart disease (-)

 FAMILY HISTORY

No one in his family has the same disease

 SOCIAL HISTORY

Smoking habit (-), Alcohol (-)

 OBJECTIVE DATA

 LOC : E4V4M5 , APP : Severely ill, Tax: 36.5 oC , BP: 130/60 mmHg ,
PR: 94 x / min, RR: 20 x / min, VAS: 0/10

 EYE : An +/ + , ict -/-, ENT : JVP : PR + 0 cm H2O


 CHEST :

HEART, INS : IC not seen, PAL: IC left MCL ICS V, PER : RB: right PSL , LB:
left MCL ICS V AUS : S1 S2 single, regular, M(-)

LUNG : INS : symmetry D/S, PAL : VF N/N , PER : sonor / sonor , AUS :
Ves +/+, Rh +/-, wh -/-

 ABDOMEN : INS: Distension (-), AUS : Bowel sound (+), PAL: Defans
Muscular (-) ,Liver and spleen impalpable, PER: Tympani, Shifting
dullness (-)

 EXTREMITY :Pedis S : Necrotic (+), Pus (+), Cold, Pulsation of A. Dorsum


Pedis is dificult to evaluate.

 LABORATORY DATA

CBC

WBC : 39.8

Neu : 37.2 (93.6%)

Lym : 0.6 (1.6%)

Eos : 1.7 (4.4%)

Mono : 0.07 (0.18%)

Ba : 0.06 (0.15%)

Hgb : 8.4

HCT : 26.5

MCV : 80.3

MCH : 25.4

Plt : 526
 Blood Chemistry

SGOT : 32.9 , SGPT: 28.4 , BS : 182 , BUN : 84 , SC : 6.4 , Uric : 10.2

UL

pH 5

Leukosit +3

Nit -

Prot +2

Glu +1

Keton -

Uro N

Bili +1

Eri +3

Sedimen

Leu Many

Eri 2-3

Epitel -
gepeng
Cyli -

Crist -

Bact -

AGD

pH 7.37

Pco2 30

Po2 89

HCO3- 17.3

BE -8.0

SO2 97%

Na 104

K 5.4
 Ni Made Molong / F / 79 YO, ADD: Jl Sudeta no 77 Ubud,

CC : Decreased of conciousness

ANAMNESIS

 Patient came with decreased of conciousness since 5 hours PTA. The family recognized that
the patient was difficult to communicate with since then. 1 day PTA patient was said to be in
normal condition and could did her daily activity well . 10 days PTA patient complained gum
bleeding and went to dentist and has her tooth fixed . Patient was also complained with
bluish red spots on her body since 10 days PTA. Fever was denied, Blackish stool was
previously unkown by the family until physical examination showed otherwise. Epigastrial
pain was previously complained by the patient since long time ago. History of pain relieve
drugs were denied. Since this afternoon patient had decrease in passing urine.

PAST MEDICAL HISTORY

History of easy bruishing before ( -)

Ht (-), DM (-), Heart disease (-)

FAMILY HISTORY

No one in his family has the same disease

SOCIAL HISTORY

Patient was unemployed .

OBJECTIVE DATA

LOC : E3V3M4 (GCS: 12)

APP : Severely ill

Tax : 36,6oC

BP : unpalpable  after loading NaCl 0,9 % 1500cc  100/60 mmHg

PR : 136 x / min, weak, irregular

RR : 20 x / min

VAS : 0/10

EYE : An +/ + , ict -/-


ENT : JVP : PR + 0 cm H2O

CHEST :

HEART

INS : IC not seen

PAL : IC left MCL ICS V

PER : RB : right PSL

LB : left MCL ICS V

AUS : S1 S2 single, regular, M(-)

LUNG :

INS : symmetry

PAL : VF cannot evaluated

PER : sonor / sonor

AUS : Ves +/+, Rh -/-, wh -/-

UL

pH 5,0

Leukosit -

Nit -

Prot -

Glu 50

Keton -

Uro 1,0
Bili 1,0

Eri -

Sedimen

Leu 0-1

Eri -

Epitel gepeng 1-2

Cyli -

Crist -

Bact +

AGD

pH 7.51

Pco2 23.0

Po2 182

HCO3- 18.3

BE -4.6
SO2 100%

Na 134

K 3,8