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INTERNA DEPARTMENT
EMERGENCY ROOM
IDENTITY
Name
: Mrs. Kastini
Age
: 50 y.o
Sex
: Female
Address
: Landean RT2 RW1 Klotok Plumpang
Tuban
Date of examination : August 26th, 2015
ANAMNESIS
Chief complaint
Shortness of breath
Present Illness History
PRIMARY SURVEY
A: clear, gargling (-), speak fluently (-), potensial
obstruction (-)
B: spontan, RR: 36x/mnt, kusmaul breathing,
ves/ves, Rh+/+, wh-/-, SaO2 100% with NRM O2
10lpm
C: akral Cold, Dry, Pale, CRT <2, PR: 93x/mnt, BP:
195/100 mmHg
D: GCS 345, lateralisation -, Round Pupil isokor 3
mm/3mm, LR+/+
E: temp 36C, urine output 100 cc
SECONDARY SURVEY
H/N
: a+/i-/c-/d+,
Chest
: sim/sim, ret+/ret+
Lung
: ves/ves Rh+/+ wh-/ Heart
: S1 S2 single, murmur -/-,
gallop -/ Abdomen : soepel, met -, bowel sound +
normal, H/L unpalpable, Epigastric pain (+)
Extremity : aic -/-, CDP, pretibia edema
PLANNING DIAGNOSIS
DL
SE
RFT
LFT
Thorax photo
ECG
Blood Gas Analysis
UL
Keton
LABORATORY FINDING
GDA : 361 mg/dl
Eritrocyte : 1.95
Hematocrit : 19
%
Hb : 5.7 mg/dl
Limphocyte: 4.5
Basophil: 2.4
Eosinopil : 1.8
Monocyte : 1.6
Leucocyte :
19.000
Neutrophyl: 89.7
Trombocyte :
661.000
Chloride : 107
Natrium : 142
kalium 6.0
Ureum 170
Kreatinin : 7.2
Be : -11.8
Beecf: -12.8
HCO3 : 14.8
PCO2 : 47
pH :7.150
PO2 : 194
SO2 : 99
SGOT : 28
SGPT : 59
THORAX AP
TIDUR
ECG
Female, 50 y.o
Dyspnea continously
nauseous and vomit
itchiness
Hypertension
Anemis
Rhonchi +/+
hiperglikemi
hiperkalemi
azotemia
Leukocytosis
Asidosis metabolic
ASSESMENT
Hypertension Emergency
DM type II
SIRS
Anemia
Hyperkalemia
Asidosis metabolic
ALO
CKD
PLANNING THERAPHY
PROGNOSIS
Dubia ad malam
Patient compliance
Vital sign
urination production