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Physical Examination
General appearance Blood Pressure Pulse Rate Looked midly ill, GCS 456 W: 60 kg H: 158 cm BMI:24 kg/m2 130/80 mmhg 88 bpm, strong regular
Respiration rate
T ax Head Neck Thorax Heart
24 tpm (W)
36.2C Anemic (+ ), Icteric (-), face edema, NGT + cofee ground JVP R + 0cm H2O Ictus invisible palpable in MCL S ICS V RHM sternal line D, LHM as Ictus S1 S2 single, murmur Insp: D=S Symmetric Palp: Stemfremitus D=S Perc: S S SS SS Ausc: V V rh: - - wh: - VV --VV ---
Lung After HD
Abdomen ,Extremities
Flat ,Soefl, Liver span 8 cm, troube space tympani , BS (+) N, epigastic pain (-) , meteorismus (-) Leg Oedem +, pale +, RT (-)
Laboratory finding
Lab Leucocyte Haemoglobin Value 8.100 /L 3.3 g/dl Lab Na K Value 135 4.7 Mmol / L Mmol / L
MCV
MCH
PCV Thrombocyte RBS Ureum Creatinin eGFR
81 um3
29.6 pg 9.0 % 230.000 /L 130 mg/dL 285.9 mg/dL
Cl
OT PT
107
18 15
Mmol / L
U/L U/L
Albumin
2.18
urinalysis
SG =1.015 Glucose (-) PH = 6.0 Protein : ( +4) Ketone (-) Ery (+3 ) Nitrite:(-) Ery : ( 10-15 )hpf Crystal (-) Bactery: ()
ECG
ECG
Sinus rhythm, HR : 86 tpm PR interval : 0.12 QRS interval :0.08 QT interval :0.4 Frontal Axis : Normal Horizontal Axis : normal Conclusion : Sinus rhythm with HR 86 bpm,
PROBLEM LIST
INITIAL DIAGNOSE
PLANNING DIAGNOSE
PLANNING THERAPY
PLANNING MONITORING
1.M/15 yo Ax:
Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, decrease of appetite swelling all of his. Already diagnosed with renal disease didnt controlled routinely, the last medication he got furosemid, captopril, and folic acid. Some time he also felt shortness of breath if he done a hard work, and the SOB became relived with rest.
1. CKD st 5
Renal biopsy
-. Renal diet 1700 kcal/day with protein 0.6-0.8mg/kg/day, low salt < 2 gr/day, cholesterol <300 gr/day -.Venflon -. Semi fowler position -. Negative fluid balance 500 cc/day -. Inj : Furosemid 40 mg-40 mg -0 -HD
PD:
RR: 24 tpm , conjungtiva anemic, edema at face, leg, extremity looks
pale Lab; Hb: 3.3, ur/cr : 285.9/ 26.98, eGFR: 3.8, albumin 2.18, proteinuria: +4, eritrocituria+3,
PROBLEM LIST
INITIAL DIAGNOSE
PLANNING DIAGNOSE
PLANNING THERAPY
PLANNING MONITORIN G
2 M/15 yo Ax: Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, PE: BP 130/80, PR: 88 tpm
RR: 24 tpm, conjungtiva anemia +, extremity looks pale, NGT + coffee ground
2. Upper GI bleeding
Endoscopy
-. NGT gastric lavage Bleeding, Hb per 8 hr, 1 time negatif fluid diet. -. Bolus omeprazole 80 mg continous with drip omeperazole 8 mg/ hr until 72 hr or bleeding was stop
Lab; Hb: 3.3, MCV 81 MCH 29.6, ur/cr : 285.9/ 26.98, eGFR: 3.8,
PROBLEM LIST
INITIAL DIAGNOSE
PLANNING DIAGNOSE
PLANNING THERAPY
PLANNING MONITORIN G
3 M/15 yo Ax: Patient suffered from vomiting the last days accompanied with coffee ground vomiting just 1 time about glass, PE:
conjungtiva anemia +, extremity looks pale, NGT + coffee ground
Hb
Lab; Hb: 3.3, MCV 81 MCH 29.6, ur/cr : 285.9/ 26.98, eGFR: 3.8,
4. M/15 yo Ax: decrease of appetite swelling all of his. Already diagnosed with renal disease didnt controlled routinely, albumin 2.18, proteinuria: +4,
Protein esbach