CLINIC TUTORIAL

KEPANITRAAN KLINIK RSI SULTAN AGUNG

Patient’s Identity Name : Mrs. SAge : 51 y.oSex : FemaleAddress : Terboyo Wetan Rt.01/Rw.02 Genuk,

Semarang.MR number : 01.11.75.67Room : Baitul Izzah 1Status : JKN Non-PBIEntry date : july 31th 2015Out date : Agustus 04th 2015

History Taking

A patient has came to the emergency department caused by she has been black out. Her family confirmed that she had a headache for a couple days ago. This symptoms completed with some nausea and vomitting. When she awakened, she also said that she often felt so weak

Medical History

• Hypertension (+)• Diabetes Mellitus (+)• Drug allergy (-)• Gastritis (-)

Family’s Medical History• Same disease (-)• Hypertension (-)• Diabetes Mellitus (-)• Cardiac disease (-)

Social Economic History

• Private Sector• Guaranteed by National Medical Insurance “JKN Non-

PBI”

General : weakSkin : itch (-), jaundice (-), pale (+), dry skin (+)Head : headache (+)Eyes : blurred vision (-), red eyes (-)Ears : hearing loss (-), ring (-), discharge (-)Nose : epistaxis (-), discharge (-)Mouth : cyanosis (-), thrush (-), bleeding gums (-)Throat : pain swallow(-), hoarseness (-)Neck : enlargement of the gland (-)Chest : cough (-), sputum (-), blood (-) Dyspneau (-)Cardiac : chest pain (-), palpitation (-)Digestive : Abdominal pain (-),naussea (+),vomit (+), diarrhea(-) Musculoskeletal : weak (-), rigid (-), back pain (-) Extremity : oedem extremity ( -/-)

Systemic Medical History Taking

Physical Examination

Vital Sign

• BP = 150/100 mmHg• Pulse = 80 x/menit • RR = 22 x/menit • T = 36,5 0C

Status Present

• Sex : Female • Age : 51 y.o• Weight : 50 kg• Height : 155 cm• BMI :

20,83(normoweight)

General : weaknessAwareness : composmentis

general Weaknessskin Ikterik (-)head mesocephalEyes Red eye (-), conjunctiva anemis (-/-), sclera icteric (-/-),

exoftalmus (-)ear discharge (-)nose epistaxis (-), discharge(-)mouth sianosis (-) ,bleeding gums (-), stomatitis (-), pain

swallow (-), pharinx hiperemis (-)neck Thyroid enlargement (-)Cardiovascular Palpitation (-)

respiratory Dyspneu (-)gastrointestinal Abdominal pain (-), nausea (+), vomiting (+), diarrhea (-)

muskuloskeletal Weakness (-) , atrofi (-), tremors (-)

Central nervous (-)

THORAX - PULMOINSPEKSI ANTERIOR POSTERIORSTATIC RR : 22x/min,

Hyperpigmentation (-), tumor (-), inflammation (-), spider nevi (-), Hemithorax D=S, ICS Normal, Diameter AP < LL

RR : 22x/min,Hiperpigmentasi (-), tumor (-), inflammation (-), spider nevi (-), Hemithorax D=S, ICS Normal, Diameter AP < LL

DINAMYC The movement of hemitorax D=S, abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS (-)

The movement of hemitorax D=S, abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS (-)

PALPATIONPalpation pain (-), tumor (-), enlargement of ICS (-), Stem fremitus D=S

Palpation pain (-), tumor (-), enlargement of ICS (-), Sterm fremitus D=S

PERCUTIONSonor +/+ Sonor +/+

AUSCULTATION

ronchi (-) , wheezing (-) , vesikuler (+) D=S

ronchi (-) , wheezing (-) , vesikuler (+) D=S

THORAX - CORINSPECTION

Unseen Ictus CordisPALPATIONIctus cordis is palpable at ICS V, 2 cm lateraly from left mid clavicula line, thrill (-)

PERCUTION

Upper borderline Waist

Lower right borderline Lower left borderline

: ICS II left sternal line: ICS III left parasternal line: ICS V right parasternal line: ICS V front axilla line

AUSCULTATIONS1 & S2 (+), Additional sound (-),

Abdomen 1.Inspection convex of surface(+), sycatric(-), striae(-), enlargement of

vena (-), caput medusa (-)

2.Auskultasi peristaltic (12x/minutes), aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)

3. percussion tympanic all abdominal surface,Liver span : dex = 12cm ; sinistra = 6cm, area troube (+)

4. palpation mass (-), pain (-) , hepatomegali (-), Spleenomegali (-) Murphy’s sign (-)

Extremity

Ekstremity Superior Inferior

Oedem -/- -/-

Cold extremities -/- -/-

Physiological Reflect +/+ +/+

Ikteric -/- -/-

Impression Normal

Laboratory Examination

Result unit Normal Value

Haemoglobin 8,1 g/dl 11,5 – 15,5

Hematocrite 25,5 % 33 – 45

Leukocyte 12,9 thousand/uL 3,6 – 11,0

Platelet 436 thousand/uL 150 – 440

Blood type / Rh A/+

result value

Blood Sugar 176 mg/dl 75-110 mg/dl

Quality HBsAg Non-reactive Non-reactive

Result Normal ValueBlood Chemical

Ureum 57 mg/dl H 10-50 g/dl

Blood Creatinin 3,54 mg/dl H 0,5-0,9 mg/dl

Natrium 136,3 mmol/L 135-147 mmol/L

Kalium 4,73 mmol/L 3,5-5 mmol/L

Chloride 114,9 mmol/L H 95-105 mmol/L

Abnormality Data

History Taking :• Nausea• Vomiting• Headache• Weakness• Pale

Physical Examination:

• Dry Skin• Pale

Laboratoric Examination:

1. Low Hb 8,4 2. Low Ht3. High Ureum4. High Creatinin5. High Chloride

PROBLEM LIST1. Chronic Kidney Disease

Chronic Kidney Disease• Ass : 3rd Grade CKD • IP Dx : Ureum, Creatinin, Blood Test, Electrolite (Na, K), Kidney Function Test• Ip Rx :

– Non PharmacologicLow Protein Consumption

– PharmacologicR/ Amlodipin 5mg 1x1

R/ Valsartan 80 mg 1x1R/ Ondancetron 4mg 3x1R/ Omeprazol 2x1R/ Renal Protector 2x1

IP.Mx : Blood Test, Ureum, Creatinin

Calories needed

• IW = (155 – 100)-10%.50 = 50 ( weight 50 normo)• 50x 25 = 1250 kal / day• Age > 40 = -5%• Activity mild = +10%• Metabolic stress = 20%• TOTAL = 1250 + (25%.1250) = 1250 + 312,5 = 1562,5

Patient with DM & CKD• 1562,5 breakfast 25%, lunch 30%, dinner 25%,

snacks between 2 big meals 10%. All portion of dishes must contain less percentage of proteins about 35g a day, less kalium, less phospat, and drink limitation using last day urinating + IWL (500cc)

• Conclusion : – Carbo 60%, protein (35g), fat (20%), no fruits, no

milk, no cocoa,

TERIMA KASIH