lapjag kamis
TRANSCRIPT
-
DUTY REPORTJANUARY 22TH 2014
Doctor in charge: dr.Rizky dr.ArlisCoass in charge: Try, Nurmalida
-
PATIENT RECAPITULATIONInpatient: 6 patientsOutpatient: 3 patientsWard: 3 patients
-
Patientss IdentityName: Mr.DSex: MaleAge: 51 y.oJob : TNI ADReligion: IslamMarital status: MarriedAddres: BTN KORPRI
-
ANAMNESISAutoanamnesa on January 22nd 2014 at 8 PM in the ER at RSPAD Gatot Subroto
Chief complain: noneadditional complain: none
-
CURRENT ILLNESSPatient was reffered to RSPAD with achalasia. 5 years before admission he felt dysphagia, nausea-vomit. And get worsed the last 2 weeks. Vomit, fever, abdominal pain were denied, defecation normal, urination normal
-
PAST ILLNESSHypertension (2013, uncontrolled)Heart desease deniedDiabetes deniedUric acid deniedCronic cough denied
-
Family illnessHypertension deniedHeart desease deniedDiabetes deniedStroke deniedMalignancy denied
-
Habits and lifestyleHeavy smoker for 10 years ( 1 2 packs a day )Stopped 5 years
-
Physical examinationVital signGeneral state: moderate sicknessConsciousness: compos mentisBlood pressure: 220/110 mmHgPulse: 75 bpmRespiratory rate: 24 bpmTemperature: 36 oCBody weight: 50 kgBody weight: 160 cm
-
Physical examinationGeneral examinationHead : Normocephaleye:anemic conjunctiva (-/-), icteric sclera (-/-)Ears:normotia, discharge (-/-)Nose: Septum deviation (-), discharge (-)Mouth: Oral trush (-), leukoplaki (-)Neck: lymph nodes enlargement (-)Thorax:symetric, intercostal retraction (-)
- Cor: regular 1st and 2nd heart sound, murmur (-), gallop (-).pulmo: vesicular breathing sound, rales (-/-), wheezing (-/-)Abdomen: distended (-), bowel sound within normal limit, tympanic, hepar & lien not palpable, absence of pain.Extremitas : warm, pitting edema (-), clubbing (-), cyanosis (-), CRT
-
Diagnostic plan LABORATORIUM
ResultNormal RangeHb12.513-18 G/DLHt3540-52%Erithrocyte4.24.3 - 6.0 Juta/nlLeukocyte88004.800 10.800/nlThrombocyte204000150.000 400.000/nlMCV8220 96 flMCH3027 32 pgMCHC3632 36 g/dl
-
ureum18020 50 mg/dLCreatinin4,60,5 1,5 mg/dLRBS (Random Blood Sugar)90
-
ECG
-
Esophagus duedonoscopy
-
RESUMEPatient was admitted into ER at 8 PM. Patient was reffered to RSPAD with achalasia. 5 years before admission he felt dysphagia, nausea-vomitting. And get worsed the last 2 weeks. Patient have hypertension since 2013, uncontrolled.On physical examination, blood pressure 200/110 mmHg. And on additional examination there are find Ureum: 180 mg/dL Creatinin: 4,6mg/dLKalium: 5,5 mmol/L
-
PROBLEM LISTAchalasiaEmergency hypertensionAcute kidney injury
-
ASSESSMENTEmergency hypertensionPhysical examination: blood pressure: 200/110 mmHgAdditional examination:Ureum: 180 mg/dLCreatinin: 4,6 mg/dLKalium: 5,5 mmol/L
-
Acute kidney injuryUreum: 180 mg/dLCreatinin: 4,6 mg/dLKalium: 5,5 mmol/L
-
TherapyIVFD RL 10 dpmISDN 5 mg SL
-
PrognosisQua ad vitam: dubia ad bonamQua ad functionam: dubiaQua ad sanationam: dubia