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Patient Identity
Name
Sex
Age
Address
Occupation
: Mr. I
: Male
: 74 y.o
: Jl.Alalak Dalam Banjarmasin
: Swasta
Physical Examination
General
Appearance
Moderately ill
Blood Pressure
110/60 mmHg,
Pulse Rate
Respiration
Rate
29 x/m
Temperature
36,6o C
Skin
nodul (-)
General
Appearance
Physical Examination
Head
Pale conjunctiva (-/-), Jaundice sclera (-/-), decreased visual acuity (-/-), Edema palpebra
(-/-), Diplopia (-), discharge (-/-), anemic konjungtiva (+/+)
Neck
Chest Heart
Lung
Abdomen
Extremities
Sponsored by XXVI-I
No. Problems
Data Support
1.
Cough
Fever, which may be mild or high
Shortness of breath
Auscultation :
BV | BV
BV | BV
BV | BV
Wheezing (-), Ronchi (-)
2.
Normocytic
normoochromic Anemia et
chronic imflamatory
Hb 8,5
MCV normal
MCH Normal
MCHC Normal
3.
History of Hypoglikemia:
GDS 300
Dm tipe II
153
1.
Problem
Pneumonia
with sepsis
P.Dx
-CXR
-Blood test
P.Tx
Ceftriaxon
P.Mo
-General
state
-Complaint
-Vital sign
P.E
(-)
2.
No
Problem
P.Dx
Normocytic
normoochromi
Liver fungtion
c Anemia et
Renal fungtion
chronic
imflamatory
Problem
Azotemia
Renal :
3.
-DM nefrotik
-Sepsis
P.Dx
-Ureum
-Creatinin
P.Tx
Transfusi prc
Zat besi
Eritropoitin
P.Tx
P.Mo
-General
state
-Complaint
-Vital sign
P.E
(-)
P.Mo
-General
state
-Complaint
-Vital sign
P.E
(-)
4.
No
5.
Problem
P.Dx
P.Tx
History of
Hypoglikemia: -GDI
-GDII
Dm tipe II
Problem
Pansitopenia
+ Leukositosis
P.Dx
HB
Trom
BMP
P.Tx
P.Mo
P.E
-General
state
-Complaint
-Vital sign
-Lifestyle
Modification
-Medication
compliance
P.Mo
P.E
-General
state
-Complaint
-Vital sign
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