Departement of Internist

Pavilion Marwah, 10th March 2013 (14.00- 07.00 am)

Identity
Name Age Religion Date

No.

MR

: : : : :

Mr. K 35 YO Moeslim 10 March 2013 19.54.19

Anamnesis
Chief complaint: abdominal pain Present illnes: Patient complained about his abdominal pain since 2 month before hospitalized. He felt nausea (+), vomit (-), abdominal discomfort (+), fever (-). Patient also complained about his swollen leg since 3 month ago. But the patient didnt know which part of the body get swelling first. Patient also complained about pain in his waist. This pain could reduce by drinking water.

History or past illness : He had history of hypertension and gastritis. Hypercholesterol and diabetes denial History of liver disease (-) History of family (-) History of sociality:

Herbal medicine, coffee, soft drinks and energy drink

consumption (+)

 Physical Examinations
General

Appearance : weak GCS : 456 Vital sign :

BP : 145/100 mmHg Pulse : 112 bpm RR : 26 x/minutes T : 38 C

 Physic Examinations
Head and neck : Anemic -/icteric-/cyanosis-/dyspneu-, edema palpebra (minimal) Thorax : I : simetric bilaterally +, retraksi -/P : ICS normal P : sonor/sonor A : ves/ves, rh-/-, whz-/RR : 22x/minute, spontan Cor : S1 S2 single, M-, G

Abdomen : I : distended, mass (-) P : Soefl, tenderness (-), Murphy sign (-) P: Tymphani (+) A : Bowel Sound (+) Nomal, Met (-) Extremity : Dry and warm to touch CRT< 2 detik Pitting edema +

Laboratory Findings

Diff count: 0/0/91/8/1 Hematocrite: 36,6 % Hb 12,1 mg/dl LED : 96/98 Leukocytes : 16.900 Thrombocyte : 365.000 HBs-Ag Negatif Alkali phospatase : 138 U/L Bilirubin direk : 0,11 mg% Bilirubin total 0,30 mg% SGOT/SGPT : 30/21 U/L

Albumin 1,2 mg % (3,5 5,5 mg%) Globulin 3,0 gr % Total protein 4,2 mg% (5,8-8,7 mg%) Clorida serum 104 (70-108 mol/l) Kalium serum 3,2 (3,6-5,5 m mol/l) Natrium serum 133 (135-155 m mol/l) Urea 39 mg/dl Serum creatinin 0,9 mg/dl Uric acid 5,1 mg/dl

Photo Thoraks

USG Abdomen

Clue and cue

Man, 35 year-old Abdomnal pain, nausea (+), vomit (-), abdominal discomfort (+), fever (-) Body swelling Pain in his waist and reduce by drinking water Herbal medicine, coffee, soft drinks and energy drink consumption (+) Chest x-ray : efusi pleura bilateral USG abdomen : Nephritis acuta bilateral, Ascites, Efusi pleura bilateral

Assessment

Suspect Nephrotic syndrome + sekunder infection Pleural effusion bilateral

Planning

Planning Dx :

Planning Tx :

UL Profile lipid

O2 nasal 2 lpm Pasang DC Infus Asering 1000cc/24h Inj. Antrain 3x1 Inj. Methylprednisolone 1x125mg Inj. Ranitidin 2x50 mg Inj. KCl 25 meq/12jam Inj. Ceftriaxone 2x1 c/ internist

Prognosis
Dubia

ad bonam

Education
Explain

to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.