30 maret huzaini ckd
TRANSCRIPT
-
8/18/2019 30 Maret Huzaini ckd
1/14
Summary of Data Base Mr. Huzaini / 53 yo /w.26 Anamnesis : Autoanamnesis Chief Complaint : Black tarry stool
•Patient suered from black tarry stool since 5 hours before
admission, blacktarrystool 4x about one glass of mineral
ater each, soft consistency, faulty odor, didn!t accom"anied
by fresh blood and mucus#
•$e also com"lained about %omiting, red colored, &x, '()
s"oonful, consisted of ater and food remains at 5 hours
before admission, ha""ened before black tarry stool#
•*ast year $e "erform ligation for treatment his bleeding#
-
8/18/2019 30 Maret Huzaini ckd
2/14
• $e diagnosed $e"atitis + infection since ) years ago, and
routinely controlled at astro out"atient clinic at -SSA, $e
got *esichol 'x& and "ro"ranolol 'x& for the treatment
• Family History : $is "arents already "assed aay,
has . siblings, /o one in his family has history of 0aundice1
chronic li%er disease#
• Past Mei!al History : hos"itali2ed &) times ith the
same com"lained
• "o!ial history : $e as married, has 4 children#
-
8/18/2019 30 Maret Huzaini ckd
3/14
Physical 3xamination
eneral a""earance: looked moderately ill +S 45 AS: 67&6
BP 8 &6676 mm$g P- 8 ' regular,strong
-- 8 &. t"m, 9ax : )#5 +
$ead Anemic con0uncti%a;P - < 6 cm$'? at )6˚ lym"hnode enlargement ;(=
+hest $eart: @ctus in%isible and "al"able at @+S & cm lateral, +* Sinistra
*ung: Stem remitus D8S S S -h ( ( Ch ( ( S S ( ( ( ( S S ( ( ( (
Abdomen and enital
-ectal 9oucher
at, soe, boel sound normal, e"igastric tenderness ;(=, li%ers"an . cm, 9raube!s s"ace : dullSphincter tonus (+), mucosa: smooth, sulcus medianus palpable, melena (+)
3xtremities
Erine out"ut
?edema ( @ (( @ (
'#5 cc7hrs
-
8/18/2019 30 Maret Huzaini ckd
4/14
*aboratory inding, >uly th '6&5*ab alue *ab alue
*eukocyte &&,'F6 ),566(
&6,)667G*
/atrium &)6 &)(&45
mmol 7 *
$emoglobine+
F#66F5#.6
&(g7dl.6(HF f*
Ialium 5#6) )#5(5#6 mmol 7*
+$ ''#66 '#5())#5
"g
+hlorida &&& H.(&6 mmol 7
*P+ '4#&6 )5(56J Albumin )#66 )#5(5#5 g7d*
9rombocyte .&,666 &46,666(4'4,6667G*
-BS &)4 K'66
3u7bas7/eu7*
y7o
6#676#&7FF#)79#& J S?9 )F 6(4&E7*
Ereum .5#)6 &6(56mg7d*
SP9 '' 6(4&E7*
+reatinine && 6,F(&,5mg7d*
-
8/18/2019 30 Maret Huzaini ckd
5/14
+L-, arc )6th '6&5
-
8/18/2019 30 Maret Huzaini ckd
6/14
+L- @nter"retation
• AP "osition, asymmetric, enough I, lessins"iration
• Soft tissue and Bone normal
• 9rachea in the middle
• $emidia"hragm D and S ere dome sha"ed,• Phrenico costalis angle D and S ere shar"
• Pulmo D7S: @ncreased BP
• +or: site /ormal
+onclusion : normal +L-
-
8/18/2019 30 Maret Huzaini ckd
7/14
3+, arch )6th '6&5
-
8/18/2019 30 Maret Huzaini ckd
8/14
3+ @nter"retation
• Sinus -hythm, $eart rate F6 b"m• rontal Axis : normal
• $ori2ontal Axis : counter clockise rotation
• P- inter%al : 6#& M
• N-S com"lex : 6#64 M
• N9 inter%al : 6#) M
• +onclusion : sinus rhythm ith $- F6 b"m,
-
8/18/2019 30 Maret Huzaini ckd
9/14
+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu
ale75) yoAx:(Black tarry stoolsince 5 hours before
admission($istory of $e" +infection
P3:(BP: &&67F6 mm$g(P-: .6 t"m@nserted /9:
bronish-9: elena <
*ab:($emoglobin : F#66g7d*(+ : F5#.6
(+$ : ''#66 "g
$ematemesis <elena
& -u"tur3
'
Pud) astritiserrosi%e
3ndosco"y
(@nserted /9astric *a%age
)xclear luid diet x'66 cc %ia /9
(@nf# /a+l 6,HJ '6t"m(@n0# *an2o"ra2ole&x)6mg(in0# etoclo"ramid)x&6mg
(Sub0ecti%e(ital sign;BP, P-=(astric
la%age7.hours(melena
-
8/18/2019 30 Maret Huzaini ckd
10/14
+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu
ale75) yoAx:(history of sakitkuningM 4 years ago
($istory of $ea"atitis+ @nfection ) yearsago
P3:(BP: &&67F6mm$gMsakit kunitM 4years ago
(P-: .6 t"m@nserted /9:bronish-9: elena <
*ab:($emoglobin : F#66
g7d*(+ : F5#.6 (+$ : ''#66 "g
'# +irrhosis$e"atis
'#& $e"atitis+ infection
3ndosco"y
9reat underlyingdisease
(Sub0ecti%e(ital sign;BP, P-=
-
8/18/2019 30 Maret Huzaini ckd
11/14
+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu
ale75) yoAx:(Black tarry stooland bloody
%omiting since 5hours beforeadmission
Pe :(BP: &6676mm$g(P-: ' t"m
(+on0uncti%aanemic ;
-
8/18/2019 30 Maret Huzaini ckd
12/14
+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu
ale75' yoAx :( *i%er diseasesince ) years agoPe:BP: &6676 mm$g
Albumin : )#66 g7dl
)#$y"oalbuminemia
)#&$y"ercatabolic state
)#' *o untake
$igh Protein diet Sub0ecti%eital sign;BP=
Pedu: 9reatment,underlyingdisease,"rognosis
+E3 A/D +*E3 P* @D PD P9 P O
-
8/18/2019 30 Maret Huzaini ckd
13/14
+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu
ale75' yoAx :( /ausea and%omitingBP: &6676 mm$g
Ereum : .5#)6mg7dl+reatinin : &,&&mg7dl
5#A2otemia
5#& %olumede"letion
5#'$e"atorenal syndrome
-ehydration & * at 3-,continue @D /a+*6,HJ '6 d"m
A%oid ne"hrotoxicagent 3Rual uid balance
Sub0ecti%eital sign;BP=
Pedu: 9reatment,underlyingdisease,"rognosis
-
8/18/2019 30 Maret Huzaini ckd
14/14
9hank ou