case dr irwin-gita
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Anggita Nur Aziza
030.07.019
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y Name : Mrs. A
y Age : 30 years old
y Gender : Female
y Religion : Islam
y Work : House wife
y Status : Married
y Address : Istana Kosambi 76/20, Kampung
Duren RT 76 RW 20, kec.Klari,
Kab.Karawang
y Date of Admission : November 3rd ,2011
y Taken from : Rengasdengklok
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Pain in all part of abdomen since 1 weekbefore hospitalized
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y The presents patient condition started 3 months before being admitted to the
hospital. Her major complaint was pain in right lower abdomen that spread to
all of her abdomen. It felt tightness especially in right lower and middle lower
abdomen, get worsened when she eat and urinate. 2 years ago patient also
admit that she felt pain when shes urinating, it felt like prod no tingling,not
burning, still smooth no dripping when shes urinating. During that 3 months,
she always feel thirsty but her miction is a little amount, 7x times/day, total
2 aqua glass/day, the color is clear yellow, white yellowness stone came out
twice and fresh blood a half of aqua glass in her urine. 1 week before
hospitalized, she felt tightness after urinating again and white yellowness in its
color, and 3 days before hospitalized, its color changed to white nodes.
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y Patient felt more easily tired and she complained about nausea,
vomitting sice 3 months ago more than 3 times/days as much as
1 aqua glass, contain food, and fluid without blood. She also felt
shortness of breath, since 3 days before hospitalized and she
hasnt been defecated for 2 days.
y She lost her appetite, weight is decrease 10 kg in past 4
months.
y She had no fever, dizziness, cough, chest pain, no sore in back
waist and no swelling of the leg.y Since 3 days before hospitalized her complaint is not getting
better, so she went to RSUD Karawang.
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y The patient had felt the same symptoms
before she was hospitalized.
y She had no history of hypertension,
diabetes mellitus, allergy (medication or
food), liver, and cardiovascular.
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Same illness with the patient (-)
DM (-) Hypertension (-)
Asthma / Allergic (-)
Cardiovascular / pulmonary disease (-)
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She didnt exercise regularly
No Smoking
No drink alcohol No blood transfusion
Never consume herbal medicine
She used to consume emping, jeroan, jamu, tea
for 10 years
She rarely drink mineral water, only 2 glass/day
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Moderately illGeneralconditionGeneralcondition
Compos mentisConciousnessConciousness
155 cmHeightHeight
30 kgWeightWeight
12.49BMIBMI
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BP:
100/70 mmHg
HR:
88 x/min
RR:
20 x/min:
Temp:
36.00 c
VITALSIGN
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y Head
Normocephaly
y Eyes
Conjunctiva anemic -/-
Sclera icteric -/-
Pupil isokor, DLR +/+, UDLR +/+
y Ears
Normotia, secrete -/-, serumen -/-
y Nose
septum deviation (-), secrete -/-, concha is normal
y Mouth
dirty mouth (-), dry mouth (-), dirty tongue (-), normal papil, mucosa not hyperemic, teeth
caries (-)
y Throat
Tonsils T1/T1 calm, pharynx hyperemic (-)
y Neck
Lymph gland is not palpable
Thyroid gland is not palpable
JVP 5+2 cmH2O
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HEART EXAMINATION LUNG EXAMINATION
y Inspection:
Ictus cordis is invisible
y Palpation:
Ictus cordis is palpable at 5th ICS
LMCS
y Percution:
No enlargement of the heart
y Auscultation:
Regular I - II heart sound no
murmur and gallop
y Inspection:
Symmetrical
y Palpation:
Equal vocal fremitus
y Percusion:
Sonor in both lung
y Auscultation:
Vesicular breath sound in both
lung, no ronchi and wheezing
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Inspection
distended, brown skin, skin abnormality(-)
Palpation
Tenderness(+) in all of her abdomen Tense in all of her abdomen
Hepatomegali (-), splenomegali (-)
CVA (-), ballotement (-)
Percussion
Tymphani , Shifting dullness (-)
Auscultation
Bowel sound (+) normal
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y Warm acrals
y Oedem
+ +
+ +
- -
- -
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BNOBNO
y Radio opaque atsupra simfisis
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November 2nd
2011Patient result Normal range
Hb 10,5 g % 12 17 g%
Leukocyte 17.500/uL 5000-10.000/uL
Trombocyte 478.000 150.000-450.000Ht 33 % 37-48 %
GDS/reduction 128 mg/dl 80-140 mg/dl
Ureum 127,8 mg/dl 10-45 mg/dl
Creatinin 5,31 mg/dl 0.4-1.5 mg/dl
GFR(140 age) x weight x 0,85 (140 30) x 30 x 0,85
72 x plasma creatinin 72 x 5,31
= 7.33 ml/minute
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Laboratory ExaminationLaboratory Examination(2(2))November 2nd
2011Patient result Normal range
HBsAg -
Anti HBs -
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November 2nd 2011 Patient result Normal range
Color yellow
Turbidity +
Protein ++
Reduction -
Ephitelial +
Leukocytes
Erythrocytes 10-20
Crystal -
Cylinder -
Bacteria -
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Symptoms Signs Laboratory and others
Pain in all of abdomensince 1 week beforehospitalizedPain when urinate, feltlike prod, always feelthirsty, miction littleamount, the color is
clear yellow, whiteyellowness stone, freshblood aqua glass,the color changed towhite nodesFatigue
NauseaVomittingShortness of breathLoss of appetiteWeght decrease
Vital Signs :BP : 100/70 mmHgHR : 88x/mRR : 20x/mT : 36.0 0 c
Distended abdomenTenderness (+) and
tense in all of abdomen
Hb : 10.5 mmHgLeukocyte : 17.500Thrombocyte :478.000Ht : 33Ureum :127.8Creatinin : 5.31Protein : ++Sedimen leukosit Sedimen eritrosit 10-20
GFR :7.33 ml/minute
BNO : radio opague insuprasimfisi
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y Chronic kidney disease grade V ec
Vesicolithiasis
y Chronic kidney disease ec chronic
pyelonefritic
y
Chronic kidney disease ec GN chronicy Acute kidney injury
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y Chronic kidney disease grade V ec
Vesicolithiasis
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y Thoraks X-Ray
y BNO-IVP
y Ultrasound
y Renogram
y Stone analysis
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y Bed rest
y Protein diet 18 gr/days
y D5% 20 dpm i.v
y Renxamin 1 fly Tramadol 2x1 amp
y Cefoperazol 2x1 amp
y Lasix 1x1 amp
y Folic acid 3x1 tab
y Ketosteril 3x1 tab
y Neurodex 3x1 tab
y Laxadin 1x1
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Ad vitam: Dubia ad bonam
Ad Fungsionam: Dubia ad bonam
Ad Sanasionam : Dubia ad bonam
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THANK YOU
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