(01.208.5736)
Patient Identity
Name
: Mr. P
Age
: 55 years old
Sex
: Male
Religion
: Islam
JOB
: Wiraswasta
No. Medical record : 01287509
Address
: Wedung - Demak
Room care
: Baitul Izzah 1 409.1
Date in
: May 31th 2016
Date out
: June 5 th 2016
History of Illness
History of previous illness :
Hypertension history (+)
Heart disease history (+)
DM history (+)
Kidney disease history (+)
Hemodialisa history (+)
Asthma history (-)
Familys history of disease :
Hypertension history (-)
Heart disease history (-)
DM history (-)
Asthma history (-)
Systemic Anamnesis
General
Skin
Head
:headache (-)
Eyes
:blurredvision(-), red eyes(-),conjungtiva anemic (+/+),
ictericsclera
(-/-)
Ears
:discharge(-), hearingloss(-)
Nose
:nosebleed(-),discharge (-)
Mouth
Throat
Neck
: trakhea deviation (-), Lymph Hypertropy (-), enlargement
ofthe gland(-)
Chest
Cardiac
: cough(-),sputum(-),blood(-)
:chest pain(-),palpitations(-)
Digestive
:abdominal pain (-), diarrhea(-), decrease appetite (+),
nausea(+),
vomiting(+), defecate/micsi (+/+)
Musculoskeletal
: weak(-),rigid(-),back pain (-)
Extremity
Physical Examinations
General Status
General
Awareness
: Composmentis
Vital Sign
BP = 171/75mmHg
Pulse
= 83 x/menit
RR = 32 x/menit
t
= 36.5 0C
Status Present
Sex
: Mmale
Age
: 55 y.o
Weight : 60kg
Height : 163 cm
BMI
: BB(kg)/TB(m)
= 60 kg/(1,63 m)
= 22.58 (normoweight)
Chest Examination-Lung
EXAMINATION
ANTERIOR
POSTERIOR
Inspeksi
RR : 22x/min, thoracal
breathing,Hyperpigme
ntasi (-), spider nevi
(-), atrofi M. Pectoralis
(-), Hemithoraks D=S,
ICS Normal, Diameter
AP < LL
RR : 22x/min, thoracal
breathing,
Hiperpigmentasi (-),
spider nevi (-),
Hemithoraks D=S, ICS
Normal, Diameter AP <
LL
Dinamic
Up and down of
hemitoraks D=S
,muscle retraction of
breathing (-),
retraction ICS (-)
Up and down of
hemitoraks D=S,
muscle retraction of
breathing (-),
retraction ICS (-)
Palpation
Sonor (+)
Sonor (+)
Static
Percution
Auskultation
Vesicular (+),
Whezzing
Interpretation : lung
oedem (-), Ronchi
(+)
Vesicular (+),
Whezzing (-), Ronchi
(+)
THORAX COR
INSPECTION
Ictus cordis can be seen
PALPATION
Ictus cordis is palpable at ICS VI, from linea axillaris anterior
sinistra, thrill (-), pulsus epigastrium (+), pulsus parasternal
(+), sternal lift (+)
PERCUTION
Upper borderline
Waist
:
:
:
:
ICS
ICS
ICS
ICS
Lower right
borderline
Lower left
borderline
AUSCULTATION
Interpretation : Cardiomegali
S1 & S2 (+), Additional sound (-),
ABDOMEN
1.Inspection
2. Auskultasi
3. Percussion
4. Palpation
Interpretation : Normal
EKSTREMITIES
Superior
Inferior
Oedem
-/-
-/-
Akral dingin
-/-
-/-
Reflek fisiologis
+/+
+/+
Ikterik
-/-
-/-
Ekstremitas
Laboratoriums Examination
01/06/2016
Hematologi
Hb
Ht
28.3 % (L)
Leukosit
Trombosit
180 ribu/uL
Ureum
01/06/2016
Kimia
Blood Creatinin
Natrium
Kalium
Chlorida
Calcium
9.1 mmol/L
Magnesium
2.4 mmol/L
GDS
337 (H)
Interpretation :
Anemia
Leukocytosis
Azotemia
Hyponatremia
Hypercalemia
Hyperchlorida
Hyperglikemia
02/06/2016
Hematologi
Hemoglobin
Hematokrit
27.2 % (L)
Leukosit
Trombosit
185 ribu/uL
Ureum
Blood Creatinin
04/06/2016
Hematologi
Ureum
Blood Creatinin
GFR/LFG
(140-age) x Weight
72 x creatinin plasma
(140-55) x 60
72 x 9,56
5.100 = 7,409
688,32
ECG
EKG Interpretation
1.
2.
3.
Irama
Frekuensi
Axis
: Sinus
: 37x/mnt
: Lead 1 (-), AFV (-) deviasi kanan
ekstrim
4. Zona Transisi
:5. Morfologi
- P Wave
:- Interval PR
: 3 kk = 0,12 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS
: 5 kk = 0,2 sec melebar Lead II,
Lead III, AVR, AVL, AVF, V3, V4, V5, V6
- Segmen ST
: ST elevasi (-), ST depresi (-)
- T Wave
: T tall (+) V4, V5, V6
T inverted (+) AVR, AVL, V1
Interpretation : RVH, RBBB, Hipercalemia
EKG Interpretation
1.
2.
3.
Irama
Frekuensi
Axis
: Sinus
: 51x/mnt
: Lead 1 (-), AVF (-) deviasi kanan
ekstrim
4. Zona Transisi
: V5
5. Morfologi
- P Wave
:- Interval PR
: 3 kk = 0,12 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS: 4 kk = 0,2 sec melebar Lead I, Lead
II, lead III, AVR, AVL, AVF, V3, V4, V5, V6
- Segmen ST
: ST elevasi (-), ST depresi (-)
- T Wave
: T inverted (+) AVR, AVL
T tall (-)
Interpretation : RVH, RBBB
EKG Interpretation
1.
2.
3.
Irama
Frekuensi
Axis
: Sinus
: 1500/18 kk = 83
: Lead 1 (-), AVf (-) Deviasi kanan
ekstrim
4. Zona Transisi
: V4
5. Morfologi
- P Wave
: P mitral (-), P pulmonal (-)
- Interval PR
: 5kk = 0,2 sec
- Q Wave
: Q patologis (-)
- Kompleks QRS: 4 kk = 0,16 sec melebar LI, LII, LIII,
AVL, AVF
- Segmen ST
: ST depresi (+) V2, V3, V4 ST elevasi
(-)
- T Wave
: T inverted (+) V1, V2, V3, V4
T tall (-)
Interpretation : RVH, RBBB
RO THORAX
Impressions
Cor :
Cardiomegali ( Suspek LVH, LAH)
Pulmo:
Tampak infiltrat paru di lobus bawah paru kanan
USG
Impressions
- Cystitis
- Moderate hidronefrosis kanan kiri dan hidroureter
proksimal kanan kiri
- Ekogenitas kortek kedua ginjal meningkat, dengan
batas kortikomeduler kabur cenderung gambaran
proses kronis pada kedua ginjal
Echo
Impressions
Global normokinetik, fungsi LV+RV sistolik baik, LVH konsentrik, disfungsi LV diastolik
Data Abnormality
Anamnesis :
Dyspneu (1)
Weakness (2)
Nausea (3)
Vomitus (4)
Hypertension
history (5)
Heart disease
history (6)
DM history (7)
Kidney disease
history (8)
Hemodialisa history
(9)
Physic Examination
:
Conjungtiva
anemic (+/+) (10)
Cardiomegali (11)
Hipertensi (12)
Tachypneu (13)
Lab :
Anemia (14)
Leukocytosis (15)
Azotemia (16)
Hyponatremia (17)
Hypercalemia (18)
Hyperchlorida (19)
GDS :
Hyperglikemia (20)
X-Ray :
Cor kardiomegali (21)
(suspek LVH, LAH)
USG :
Cystitis (22)
Hidronefrosis &
hidroureter (23)
ECG :
RVH (24)
RBBB (25)
Hipercalemia (26)
Bradikardia with
Total AV Block (27)
Echo :
Global normokinetik
(28)
Problem List
1. CHF (1, 2, 6, 11, 13, 21, 24, 25, 28)
2. CKD (3, 4, 8, 9, 14, 16, 17, 18, 19)
3. HIPERTENSI GRADE II (3, 4, 5, 12)
4. DM TYPE II (7, 20)
5. ANEMIA (10, 14)
6. HIPERKALEMIA (18, 26)
7. CYSTITIS (15, 22)
8. HIDRONEFROSIS & HIDROURETER (23)
9. BRADIKARDIA WITH TOTAL AV BLOK (27)
CHF
Ass
Anatomi diagnosis (LVH, RVH)
Etiology Diagnosis (HHD, IHD)
IP.Dx
BNP/Pro-BNP
IP.Tx
Non Farmacology
Bed rest
of sit down position
O2 2-3 L/minutes
Diet Low salt
Farmacology
Captopril 3 x 6,25 mg
Furocemid 2x 20 mg iv
Laktulosa 1 x 1
Ip.Mx
General Condition
Vital sign
ECG
Ip.Ex
Explain about the disease
Maintain weight
Reduce salt intake and
Avoid alcohol and cigarette
Consumption drug regularly
Routine check of blood
pressure.
High fiber diet
CKD
Ass
Non Farmakology :
Diet low protein 0,6-0,8g/kgBB/day
Diet low salt 1 gram
Diet fluid 500cc + how much urine
mL/day Farmakology
:
CaCO3 3 x 500mg to prevent
hiperfosfatemia
bicnat 3 x 500mg to prevent acidosis
metabolic
Technical Therapy : Hemodialisa when
creatinin clearence tolerance decrese until
<15
IP.Mx
Balance of fluid,
Diuresis,
Vital sign
Awareness,
Chemical blood tests
Electrolyte
IP.Ex
Expalin
Explain
Explain
intake
about
about
about
disease
hemodialisa
nutrition and water
HIPERTENSION GRADE II
Ass
Maligna Hypertension
Benigna Hypertension
IP.Dx
Funduskopi
Micral test
IP.Tx
Non Farmacology
Diet low salt
Farmacology
Captopril 2 x 6,25 mg
Amlodipin 1x10 mg
IP.Mx
Vital sign
ECG
IP.Ex
Reduce salt intake, avoid
alcohol and cigarette
Mild Exercise at least 30 minute
everyday
Consumption drug regularly
Routine check of blood
pressure.
DM TYPE II
Ass
Makroangiopati (peny jantung
koroner, penyakit arteri perifer,
penyakit cerebrovasculer)
Mikroangiopati (retinopati diabetik,
nefropati diabetik, neuropati
diabetik)
IP.Dx
Funduscopy
Micral test
Ct-scan cranium
Angiography
IP.Tx
Non Farmacology
Reducing carbs and glucose
consumption
Low glucose intake dietary
Farmacology
IP.Mx
Daily blood glucose test, HBA1c,
GDPP, GDP
IP.Ex
Maintain weight
Avoid drink and eat too much carbs
and glucose
Consumption drug regularly
Routine check of blood glucose
ANEMIA
Ass
Normokrom normositer,
Hipokrom mikrositer
IP.Dx
MCH
MCV
MCHC
Retikulosit tes
Fe/TIBC
IP.Tx
SF 300 mg 3x1 tab
Vit c 500 mg 1x 1 tab
IP.Mx
Blood test (, Hb, Ht, Leukosit,
Trombosit)
IP.Ex
:-
HIPERKALEMIA
Ass
Emergency treatment
IP.Dx
:-
IP.Tx
Hemodialisa
IP.Mx
General condition
Electrolyte
IP.Ex
Bedrest
CYSTITIS
Ass
Acute
Cronic
IP.Dx
BNO or BNO IVP
IP.Tx
Farmacology
Cefixime 3 x 500
IP.Mx
:-
IP.Ex
Penggunaan antiseptik setelah
BAK
Hygiene genitalia eksterna