Beruflich Dokumente
Kultur Dokumente
Physical examination
BP = 160/100 mmHg
Tax : 36,7 C
GCS 456
Head
Pale conjunctiva +
Neck
Chest
Heart:
Lung:
Symetric, SF D= S
bv bv
bv bv
bv bv
Rh - ---
Wh
- ---
Flat, Soefl, liver span 8 cm, traube space tympani, shifting dullness (-)
bowel sound (+) normal RT : TSA normal, flat sulci medianus, mass at
superior pole, smooth surface, solid consistency, tenderness(-), blood (-)
Extremities
Oedema -/-
Skin
Generalized Erhythematous
Value
Lab
Value
Leukocyte
16260
3.50010.000/L
Natrium
127
136-145 mmol / L
Haemoglobine
MCV
13.7
87
11,0-16,5 g/dl
80-97
Kalium
4.58
3,5-5,0 mmol / L
MCH
28.2
26,5-33,5
Chlorida
`101
98-106 mmol / L
PCV
42.2
35-50%
Osmolarity
289.36
Trombocyte
92000
100.000390.000/L
SGOT
16
11-41U/L
SGPT
82
10-41U/L
<200
Eo/BasNeu/Ly/ 0/0/72/25/2
Mo
Ureum
143.1
10-50 mg/dL
RBS
472
Creatinine
1.5
0,7-1,5 mg/dL
PPT
10.62
BUN
44.57
APTT
29.10
URINALYSIS
Result
Result
SG
1.025
10 x
PH
6,0
Epithelia
Leucocyte
3+
Cylinder
Nitrite
Hyaline
Protein
1+
Granular
Glucose
2+
Leukocyte
Erythrocyte
2+
Erythrocyte
40 x
Keton urine
Eritrosit
109.2
Urobilinogen
Eumorfik
positif
Bilirubin
dismorfik
Leukocyte
113.9
Bacteria
jamur
++
Laboratory Finding
BGA
Value
(Without oxygen
supplementation)
PH
7.32
7,35-7,45
PCO2
40.8
35-45
PO2
105.8
80-100
True O2
22.4
HCO3
21.1
21-28
O2 saturation
97.6%
> 95%
Base Excess
-5.2
-3 until +3
Conclusion
ECG
PL
1. Drug
eruption
IDx
1.1 Due to
ciprofloxa
cin ?
PDx
-Skin prick
test
PTx
O2 2-4 lpm NC
IVFD NaCL 0.9% 30 DPM
Stop ciprofloxacine
injection
Inj Diphenhidramin 1
amp IV
Inj methylprednisolon
1x 62.5 mg IV
Mebhidroline
napadisilat 1 x 10 mg
PMo
S, VS, rash +
itchyness
P Edu:
Planning
diagnostic,
Prognosis, and
therapy
PL
2. UTI
IDx
2.1 catheter
related UTI
PDx
Urine
culture,
gram
staining,
sensitivity
test
PTx
-Replace catheter
Drink enough water
- Inj ceftriaxone 2x1 gram
(skintest)
PMo
S, VS,
Urine
ouput,
UL
Ped:
Diagnosis
, Therapy
UL: (HPF)
erit : 109.2, leukocyte
113.9
Male/ 58 yo/W. 27
Lab
RBS : 472 mg/dL
3. DM Type 2
newly
diagnosed
HbA1C,
FBG
2HPPBG
S, VS
FBG,
2HPPBG
PL
IDx
PDx
PTx
PMo
Male/ 58 yo/W. 27
LAB
RR : 26 tpm
Ur : 143.1
Cr :1.5
BUN/CR ratio : 44.57
4. Azotemia
4.1Prerenal
4.1 low intake
4.2 Increase of
IWL
Subj.com
plain
Urine
output
Ur/CR
Male/ 58 yo/W. 27
A
Hypertension since 1
years ago
GCS : 456
BP : 160/100 mmHg
PR : 80 bpm Regular,
strong
Tax : 36,7
5. HT grade II
5.1 Secondary
5.1.1.
5.1.2.
Subj.com
plain,VS
5.2 Primary
PL
Male/ 58 yo/W. 27
A
History of SOB
Cough
Heavy Smoker
Auscultation:
bronchovesiculer at all
area
CXR: emphysematous
lung
6.COPD (stable
condition)
Male/ 58 yo/W. 27
A
BPH was diagnosed 1
years ago
Drug hytrin but
unroutinly
Used catetherization
about 3 weeks
PE
RT : TSA normal, flat sulci
medianus, mass at
superior pole, smooth
surface, solid consistency,
tenderness(-), blood (-)
7. BPH
IDx
USG Urology
PDx
PTx
PMo
O2 2-4 lpm NC
Nebulizer beta 2 agonis (if
needed)
S,vs
Hytrine 1x1mg
Consult to urology dept
S
VS
urine
productio
nS
Hypertension
BPH
Problem analysa
Eritema all
body
3 weeks
Catetherization
BPH
UTI
Ciprofloxacin
Management analysis
bed rest
O2 NC 2 -4 L/minutes
GCS : 456
BP : 150/90 mmHg
HR : 84 bpm
RR : 24 tpm
Tax 36,7
Urine Production : 1 cc/kgbb/hour
Thank you