Beruflich Dokumente
Kultur Dokumente
IA : dr. Meci, dr. Rusyda, dr. Supono IB : dr. Vindrya, dr.Amel II : dr. Maya III: Dr.Sri Sunarti SpPD,
Physical Examination
General appearance Blood Pressure Pulse Rate Respiration rate T ax Looked severely ill GCS : 456 90/60 mmHg 100 tpm 24 tpm, 35.60C
Head
Neck Chest Heart
Lung
Abdomen Extremities
Soefl , Liver span 10 cm, traube space dullness(splenomegali s2), epigastric pain + Edema - +/ - + (pitting oedema), pale
Laboratory finding
Leucocyte Hemoglobine MCV MCH PCV Trombocyte RBS Ureum Creatinine SGOT SGPT Na K Cl LDH 7.300 6.0 73 24.7 17.6 316.000 102 17.0 0.60 13 10 139 3.8 94 % /L mg/dl mg/dL mg/dL U/L U/L Mmol / L Mmol / L Mmol / L Mmol/L /l gr/dl
Value
N: 3.500 10.000 N: 11,0 16,5 N: 80 - 97 N: 26.5 33.5 35 - 50 150.000 390.000 < 200 10-50 0,7 1,5 11 41 10 41 136 145 3,5 5,0 98 106 210-425
Lab Urinalysis
Value
Lab Value Laboratory Finding continued... 10 x Epithel Silinder Hialine Granuler Leucocyte Erytrocyte 40 x Eritrosit
SG
PH
Leucocyte
Nitrite Protein Glucose Eritrocyte
Keton urine
Urobilinogen Bilirubin
Leucocyte
Crystal Bacteria
CHEST X RAY
CXR : AP position, asimetric, KV enough, less inspirasi, soft tissue and bone normal. Phrenico costalis angle on Right and Left sharp, Hemidiaphragm D&S dome shape, Increase of BV pattern on Lung D, Thickening of hilus Cor site N, CTR 60%, Conclusion : cardiomegaly,
PROBLE MLIST
INITIAL DIAGNOSE
PLANING DIAGNOSE
PLANING THERAPY
PLANING MONITORING
Female / 28 yo 1. Anemi 1.1. Anemia Shortness of a defisiensi Fe breath,general hipokro weakness, low m intake 2 mikrosi months ter PE= pale conjunctiva HB: 6.0 gr/dl
O2 2-3 lpm CBC IVFD NS 0,9 LL Folic acid 1x3tb, B12 3x1 tab, PRC transfusion 1 pack/day till Hb> 10 gr/dl
PLANING DIAGNOSE
PLANING MONITORING
Consul Psikiatri
VS Complain
3. HF.St.C Fc III
Ecxhocardi ography
Semifowler VS position Complain O2 3-4 L/ m via N.C Furosemide 400-0 mg i.v Captopril 3 x 6, 25 mg p.o