DECEMBER 5, 2017
DEPT OF INTERNAL MEDICINE
M28
OB LIST INTERNA
Nama Diagnosis Ruangan
Ny Tonajah SH Marwah 11
Tn Sapran TB paru Arofah 5
Tnabdul halim Sepsis Igd
Ny Sumarsi Asma Igd
IDENTITY
Name : Mrs T
Age : 59 years old
Address : Tunggulan Lamongan
Admission : Dec 4th, 2017 at 20.00 PM
Abdominal pain
Treatment History :
Examined at RS Suyudi ascites punction two times @ 200 cc
DM is denied
HT + controlled
Family history
Pulse
80 x/min
Temp
36,3º C
RR
22 x/min
A: clear, gargling (-), snoring (-), speak fluently (+), potential obstruction (-)
B: spontan, RR 22x/min, ves / ves, rh -/-, wh -/-, SaO2 96% with no oxygen support
C: acral warm, dry, pale, CRT <2, pulse 80 bpm, BP 173/95 mmHg
D: GCS 456, lateralization -, Pupil : round 3mm/ 3mm, Light perception +/+
E: temp 36,3C
GENERAL STATUS
General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a +/i+/c-/d-
THORAX
Inspection
Symmetrical, retraction -
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1S2 single, M -, gallop -
ABDOMEN
Inspection
Distended, colateral vein +, spider nervi -, skin mark +
Auscultation
Met -, bowel sound WNL
Palpation
Pain (+) all region
Liver/Spleen hard to evaluated
Undulation test+
Percussion
shiffting dulness+
EXTREMITIES
Inspection
Clubbing fingers (+), icteric (+), cyanosis (-), edema (-)
Palpation
Warm and dry pale, CRT <2’
CLUE AND CUE
Female, 59 years old
Abdominal pain
Abdominal enlarged
Abdominal fullness
Anemia
Jaundice
Colateral vein+
Clubbing finger+
Shifting dullness+,
PLANNING DIAGNOSE
Chest radiography
Complete blood count
ASSESMENT
SH
anemia
LABORATORY FINDINGS
• Eritrosit. 3.62 (3.8-5.3) GDA 119
• Hb. 8.8 (13 – 18)
Albumin 4.0
• LED1. 52
• LED2. 72 SGOT 21 (0-35)
• Limposit. 6,6
SGPT 10 (0-35)
• Basofil. 1.5
• Eosinopil. 4.7 (1-2)
• Hematokrit. 27.7
• Leukosit 6.3
• Neutropil. 86.7
• MCHC 31.80
• MCH 24.30
• MCV 76.50
• Monosit 3.3
• MPV 6
• RDW 15
• Trombosit 192
RO THORAX
PLANNING THERAPY
Consult Internist
PLANNING MONITORING
Vital Signs
Patient’s complaint