Professional Documents
Culture Documents
CC : Weakness
History of DM (+) since 13 years ago and taking medication with Glikuidon
30mg OD and Metformin 500mg TID. History of Lung TB since 3 years ago
with Rotgen and BTA (+) and complit treatment in Wangaya Hospital. HT
(-), Heart disease (-)
FAMILY HISTORY
SOCIAL HISTORY
OBJECTIVE DATA
LOC : E4V4M5 , APP : Severely ill, Tax: 36.5 oC , BP: 130/60 mmHg ,
PR: 94 x / min, RR: 20 x / min, VAS: 0/10
HEART, INS : IC not seen, PAL: IC left MCL ICS V, PER : RB: right PSL , LB:
left MCL ICS V AUS : S1 S2 single, regular, M(-)
LUNG : INS : symmetry D/S, PAL : VF N/N , PER : sonor / sonor , AUS :
Ves +/+, Rh +/-, wh -/-
ABDOMEN : INS: Distension (-), AUS : Bowel sound (+), PAL: Defans
Muscular (-) ,Liver and spleen impalpable, PER: Tympani, Shifting
dullness (-)
LABORATORY DATA
CBC
WBC : 39.8
Ba : 0.06 (0.15%)
Hgb : 8.4
HCT : 26.5
MCV : 80.3
MCH : 25.4
Plt : 526
Blood Chemistry
UL
pH 5
Leukosit +3
Nit -
Prot +2
Glu +1
Keton -
Uro N
Bili +1
Eri +3
Sedimen
Leu Many
Eri 2-3
Epitel -
gepeng
Cyli -
Crist -
Bact -
AGD
pH 7.37
Pco2 30
Po2 89
HCO3- 17.3
BE -8.0
SO2 97%
Na 104
K 5.4
Ni Made Molong / F / 79 YO, ADD: Jl Sudeta no 77 Ubud,
CC : Decreased of conciousness
ANAMNESIS
Patient came with decreased of conciousness since 5 hours PTA. The family recognized that
the patient was difficult to communicate with since then. 1 day PTA patient was said to be in
normal condition and could did her daily activity well . 10 days PTA patient complained gum
bleeding and went to dentist and has her tooth fixed . Patient was also complained with
bluish red spots on her body since 10 days PTA. Fever was denied, Blackish stool was
previously unkown by the family until physical examination showed otherwise. Epigastrial
pain was previously complained by the patient since long time ago. History of pain relieve
drugs were denied. Since this afternoon patient had decrease in passing urine.
FAMILY HISTORY
SOCIAL HISTORY
OBJECTIVE DATA
Tax : 36,6oC
RR : 20 x / min
VAS : 0/10
CHEST :
HEART
LUNG :
INS : symmetry
UL
pH 5,0
Leukosit -
Nit -
Prot -
Glu 50
Keton -
Uro 1,0
Bili 1,0
Eri -
Sedimen
Leu 0-1
Eri -
Cyli -
Crist -
Bact +
AGD
pH 7.51
Pco2 23.0
Po2 182
HCO3- 18.3
BE -4.6
SO2 100%
Na 134
K 3,8