DM in charge
Amuthen Karunagaran
Supervisor :
Dr Fajar SpPD
SUMMARY OF DATABASE
Mrs. T/53 y.o / W.28
Chief Complain: Stomach ache
Family History :
No history of diabetes and hypertension in her family.
Allergy :
No known history of food or drug allergy.
PHYSICAL EXAMINATION
General appearance looked moderately ill Looked normoweight
GCS 456
BP 110/70 mmHg PR = 80 bpm RR = 18 tpm Tax =36,4 0C
Head Conjuctiva Anemic (+) Sclera Icteric (-)
Ureum 33 16,6 -
42,5mg/dl
Creatinine 1.16 < 1,2 mg/dl
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/52 y.o. 1. 1.1 PUD Endoscopy Inj. Omeprazole S, VS
History Dyspepsia 1.2 Gastritis 1x40mg
Patient came to the ER Syndrome Erosiva Inj. Metoclopramide P.Edu:
with chief complain of 3x10mg explanatio
nausea and vomiting about n about
6 times a day, volume is the
about one small cup and disease
contains food. and
Patient also complained of treatment
stomach ache since 7 plan
months ago.
Physical examination
Epigastrial tenderness(+)
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Mr.S/ 47 yo/ W27 2. Anemia 2.1 Acute Blood - PRC transfusion 2 Complaint
Ax normokro blood smear packs/day till Vital sign
Conjunctiva anemic(+) m loss Reticulo Hb>10g/dL Subjective
normositer 2.2 Chronic cyte
PE disease count HB level
BP: 110/70 mmHg
HR: 80x/m Anemic
RR: 18x/m sign
Tax: 36.4 C
Therapy
Lab : and
HB 6.70 g/dL prognosis
MCV : 80.80
MCH : 26.60
MCHC : 33.10
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/73 YO 3. 3.1 iritable Colonoscopy -Lectulose syrup 3xcth Education:
History Constipati bowel Explain
Patient unable to defecate on syndrome about
for the past 7 days. 3.2 condition,
Weight loss(+) Malignancy planning
therapy
PE and
Adbomen rounded(+) prognosis
CONDITION THIS
MORNING
GCS : 456
BP : 120/70 mmHg
HR : 85 x/m
RR : 18 x/m
Tax : 36,8 C
THANK YOU