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FEBRUARY
4TH, 2015
Group
Ekky Ardianto C.G
Abdul Latif
Devi Rahma Yulianti
Tika Nurullita
Patients Identity
Name
Sex
Age
Occupation
Address
: Mrs. Rusdiana
: Female
: 55 yo
: Wiraswasta
: Sei. Jelai Kec. Tambang
Ulang
Hospitalized since : February 3th, 2015
Patient has lumbar pain since 1 day ago. Pain occur slowly and
heavier (score 5). Location of pain in left lumbar regio and
suprapubic. Patient felt nausea, vomit and gastric pain because of
anorexia. Patient also headache and dispnea.
History of Past illness: Hypertension, gastritis
History of Family illness:-
Physical Examination
General appearance
Vital Signs
Head
Pale conjunctiva (-/-), Jaundice sclera (-/-), Edema palpebral (-/-), Diplopia (-), discharge
(-/-), exophthalmus (-/-), lid retraction (-/-), lid lag (-/-)
Neck
Chest Heart
Lung
Abdomen
Percussion:
D | D |D
D | D |D
D | D |D
Tenderness:
- |- |- |- |+
- |+|-
Extremities
Superior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)
Inferior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)
Laboratory findings
th 2015
January
19
Examinatio Value
Referred
Unit
n
Value
Examinatio
n
Value
Referred
Value
Unit
Hb
10
12,00-16,00
g/dl
GDS
101
<200
mg/dL
leukosit
15,5
4,0-10,5
th/ul
SGOT
19
0-46
U/I
eritrosit
3,86
3,90-5,50
million/ul
SGPT
17
0-45
U/I
hematokrit
29,3
37,00-47,00
Vol%
klorida
107,5
95-100
Mmol/l
Trombosit
253
150-450
th/ul
Ureum
133
10-50
Mg/dL
RDW-CV
14,6
11,5-14,7
Creatinin
6,1
0,6-1,2
Mg/dL
MCV
76,1
80,0-97,0
fl
MCH
25,9
27,0-32,0
pg
MCHC
34,1
32,0-38,0
Gran%
84,3
50,0-70,0
Limfosit%
10,1
25,0-40,0
MID%
5,6
4,0-11,0
Gran#
13,10
2,50-7,00
th/ul
Limfosit#
1,6
1,25-4,0
Th/uI
MID#
0,8
Th/uI
Problem list
Female, 55yo
1.Lumbar pain
1.1CKD
Data Support
Planning
Diagnosis
Planning therapy
Monitor
Education
vital sign
observation
Urine control
Bed rest
Diet
renal
Ax:
Vomit
nausea
dispnea
anemisz
abdominal pain
regio lumbar sinister
and suprapubic
History of past
illnes hipertension
USG
Abdomen
Lab (ureum,
creatinin,
darah rutin)
Confirm
Diagnosis
Ranitidin
Ketorolac
Cefriaxon
Inf. RL
Px
Konjungtiva anemis
Nyeri ketok ginjal
1.2 Urethrolithiatic
Abdominal pain
regio lumbar sinister
Nyeri ketok gnjal
Rontgen w/
contrast
Confirm
diagnosis
Inj Ketorolac
3x10mg
Ranitidin
Ceftriaxon
Inf RL
Vital sign
Urine control
Thank you