REPORT

Pre-Clerk in charge:
Ruben Timothy Abednego
Amalia Diane Pratiwi
Nadiya Elfira Bilqis
Supervisor: dr. Supriono,
SpPD-KGEH

Anamnesa

Mrs. V, 65 y.o., ward 26 bed 1

History taking: heteroanamnesa
Chief complain: Decrease of Consciousness
History of present illness:
Decrease of consciousness since 1 day ago. In the
morning, patient was able to recognize her
relatives. Since afternoon, patient had slurred
speech and repeated 1-2 words. Patient also
started to forget her relatives.

Two days ago, patient vomited brown-colored fluid 2

times and always vomit directly after meal intake.
Patient looked weak but still able to make
repeated sentences. At the night, patient was
admitted to RSJ Lawang to check blood glucose
and cholesterol level, the result was normal.
Yesterday morning, patient went back to RSJ
Lawang with weakness and nausea eventhough
doctor had given anti emetic injection.
Two days ago, patient also had chest pain and
abdominal pain. There was no difficulty in
breathing and doing daily activites during day
and night. Patient usually use 2 pillows while
sleeping.

Patient was diagnosed with

hypertension and Diabetes Mellitus type
II. One year ago, patient started to
control routinely for her DM and HT. The
doctor prescribed metformin 500 mg
2x1, simvastatin, lanzoprazole, aspilet,
and valsartan 160mg.

 History of past illness and drug history:

In 1996, patient experienced mild stroke.
In 2011, patient experienced stroke with
paralysis on the left side. Patient consumed
stroke medication for 6 months.

 Family History:
Her sister suffered from heart attack and her mother had
hypertension.

Social history:
Patient was a kindergarten teacher and retired in 2000.
Patient seldom does physical exercise.

Review of System
General: fatigue
Mouth and throat: diff in swallowing
Abdomen: loss of appetite, nausea, vomiting, pain
Muskuloskeletal: left side weakness ec post stroke

Physical Examination
General Appearance: looked severely ill
GCS:
RR: 32 x Tax:
BP: 100/70 mmHg
PR: 80 bpm
456
/m
36.50C
Head
Anemic (-/-) , icteric sclerae -/Neck
JVP R+0 cm H2O, lymphnode enlargement -/Ictus visible, palpable at ICS IV 1 cm lateral MCL S
Hea Thrill: Heaves: Chest
rt
RHM ~ SL D
LHM ~ ictus
S1 and S2 single normal, murmur (-), gallop (-)
Stem Fremitus N N
Perc S S
Ausc v v Rh Wh - Lun
NN
S S
v
v
g
- - NN
S S
v
v
- - Abdome flat,bowel sound N, liver span 10 cm, Traube Space
n
Tymphany, shifting dullness -, flank pain -

LABORATORY FINDING
Lab

Value

Leucocyte

15.190

Haemoglobi
ne

(Normal)

Lab

Value

(Normal)

4.700
11.300 /L

Natrium

130

136-145
mmol/L

10,50

11,4 - 15,1
g/dl

Kalium

5,14

3,5-5,0
mmol/L

PCV (Hct)

30,50%

38 - 42%

Chlorida

89

98-106
mmol/L

Trombocyte

412.000

142.000
RBS
424.000 /L

280

< 200 mg/dl

MCV

74

80-93 fl

Ureum

538,8

20-40 mg/dL

MCH

34

27-31 pg

Creatinine

14,3

<1,2 mg/dL

MCHC

34

33-36 g/dL

RDW

14,6%

11,5-14,5%

Eo/Bas/Neu/l
imf/Mon

0/0,1/96,
9/2,5/0,5

0-4/0-1/5167/25-33/25

SGOT

13

0-32 mU/dL

SGPT

114

0-33 mU/dL

Urinalysis
Lab

Value

Normal

Color

Cloudy

Yellow

pH

5,5

4,5-8

Density

1,020

1,005-1,025

Protein

+1

Negative

Glucose

Negative

Bilirubin

Negative

Urobilinogen

Negative

Leucocyte

+3

Negative

Erithrocyte

+3

Negative

Blood Gas Analysis

Lab

Value

Normal

pH

7,36

7,35-7,45

pCO2

24,3

35-45 mmHg

pO2

165

75-100 mmHg

HCO3

13,9

22-26 mEq/L

BE

- 11,8

-2 +2 mmol/L

SaO2

99,32%

>95%

Interpretation

Metabolic acidosis fully compensated with

severe hypoxemia

PROBLEM ORIENTED
MEDICAL RECORD (POMR)

Cue & Clues

PL

IDx

PDx

PTx

PMo &
PEd

Female/65y.o.
DOC & general
weakness
GCS 356 456
Lab:
WBC 15.190
Ur/Cr 538.8/14.34
Urine
Macros: cloudy
Micros:
Leucocyte 3+
Protein 1+
Erythrocyte 3+
RBG 280 mg/dL
BGA (NRBM 10lpm):
metabolic acidosis
fully compensated

1. DOC
gradual
onset

1.1 Uremic
encephalopat
hy
1.2 Septic
encephalopat
hy
1.3
Hyperglicemic
Crisis

Blood
Cultur
e

Bed rest
O2 10 lpm NRBM
Rehydration 500cc NS in
30 min
Equal fluid balance
Soft renal diet 1800
kcal/day, low salt,
protein
1-1.2 g/kgBW/day
Infus ciprofloxacin
2x200mg
P.O: Ca polystirenate
3x1 g
HD CITO (performed)

Subjective
VS
CBC
Ur/cr
P Edu:
Diagnosis +
therapy

Cue and Clue

PL

IDx

PDx

PTx

PMo+PEdu

Female/65y.o.
History of DM
type II (2012)
DOC & general
weakness
Nausea
vomiting,
abdominal pain
GCS 356 456
Lab:
RBG: 280 mg/dL
WBC 15.190
Urine
Macros: cloudy
Micros:
Leucocyte 3+
BGA (NRBM
10lpm):
metabolic
acidosis fully
compensated

2.
Hyperglice
mic Crisis

2.1 . Mildmoderate
KAD
2.2 KAD
mixed HHS

Urinalysis
(Keton
bodies)
Serum beta
hidroxy
butyric acid

O2 10 lpm
NRBM
Rehydration
NaCl 0,9% 2L
Line 1: drip
Actrapid 8 IU/
hour
Line 2: NaCl
0,9% 20 dpm

Subjective
VS
RBG
SE
BGA
P Edu
Diagnosis +
therapy

Cue and Clue

PL

IDx

PDx

PTx

PMo+PEdu

Female/65y.o.
Urine
Macros:
cloudy
Micros:
Leucocyte 3+
Lab:
WBC 15.190

3. Urinary
Tract Infection

3.1 Lower
Urinary Tract
Infection

Urine culture
Antibiotic
sensitivity test

IV
Levofloxacine
1x500 mg

Subjective
VS
CBC
UL

Female/65y.o.
History of DM
and HT (since
2012)
Ur/Cr
538.8/14.34
Ur/Cr ratio
=37,6 (<40:1)
GFR=((14065)x65/
(14.34x72))x0.
85=4.01

4. CKD stage
V

4.1 DM
Nephropathy
4.2 HT
Nephrosclerosi
s

USG
Abdominal
Ca/P, CCT

Dietary
protein
restriction 0.60.8 g/kgBB

Subjective
VS
Avoid
nephrotoxic
drug
Ur/Cr
GFR
Urine output
Avoid
nephrotoxic
drug

Equal fluid
balance
RRT

Cue and Clue

PL

IDx

PDx

PTx

PMo+PEdu

Female/65y.o.
Loss of appetite,
nausea
vomiting,
abdominal pain

5.
Dyspepsia
syndrome

5.1 Uremic
gastropathy
5.2 Gastritis
erosive
5.2 Peptic
Ulcer Disease

Endoscopy

Metocloprami
de 3x10 mg
IV 30min ac
Lansoraprazol
e 2x30 mg
slow IV inj

Subjective
VS

Female/65y.o.
Diagnosed DM 4
years ago
RBG: 280 mg/dL

6. DM type
II
uncontrolle
d

Lifestyle
modification
OAD:
metformin
500mg 2x1
Insulin: longacting

Subjective
VS
RBG

FPG
2hPPG
HbA1c

PEdu
Disease
therapy
Prognosis

PEdu
Disease
therapy
Prognosis