CLINIC

TUTORIAL

Coass interna
RSISA
Patients Identity
Name : Mrs. S
Age : 51 y.o
Sex : Female
Address : Terboyo Wetan Rt.01/Rw.02 Genuk,
Semarang.
MR number : 01.11.75.67
Room : Baitul Izzah 1
Status : JKN Non-PBI
Entry date : july 31th 2015
Out date : Agustus 04th 2015
 History Taking

A patient has came to the emergency

department caused by she has been black out.
Her family confirmed that she had a headache
for a couple days ago. This symptoms completed
with some nausea and vomitting. When she
awakened, she also said that she often felt so
weak
 Medical History
Hypertension (+)
Diabetes Mellitus (+)
Drug allergy (-)
Gastritis (-)
Familys Medical History
Same disease (-)
Hypertension (-)
Diabetes Mellitus (-)
Cardiac disease (-)
Social Economic History

Private Sector
Guaranteed by National Medical Insurance JKN
Non-PBI
Systemic Medical History Taking
General : weak
Skin : itch (-), jaundice (-), pale (+), dry skin (+)
Head : headache (+)
Eyes : blurred vision (-), red eyes (-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : epistaxis (-), discharge (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-)
Neck : enlargement of the gland (-)
Chest : cough (-), sputum (-), blood (-) Dyspneau (-)
Cardiac : chest pain (-), palpitation (-)
Digestive : Abdominal pain (-),naussea (+),vomit (+), diarrhea(-
)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Extremity : oedem extremity ( -/-)
Physical Examination
General : weakness
Awareness : composmentis

Vital Sign Status Present

BP = 150/100 mmHg Sex : Female

Pulse = 80 x/menit Age : 51 y.o
Weight : 50 kg
RR = 22 x/menit
Height : 155 cm
T = 36,5 0C
BMI : 20,83(normoweight)
general Weakness
skin Ikterik (-)
head mesocephal
Eyes Red eye (-), conjunctiva anemis (-/-), sclera icteric (-/-),
exoftalmus (-)
ear discharge (-)
nose epistaxis (-), discharge(-)
mouth sianosis (-) ,bleeding gums (-), stomatitis (-), pain
swallow (-), pharinx hiperemis (-)
neck Thyroid enlargement (-)
Cardiovascular Palpitation (-)
respiratory Dyspneu (-)
gastrointestinal Abdominal pain (-), nausea (+), vomiting (+), diarrhea (-)
muskuloskeletal Weakness (-) , atrofi (-), tremors (-)
Central nervous (-)
 THORAX - PULMO
INSPEKSI ANTERIOR POSTERIOR
STATIC RR : 22x/min, RR : 22x/min,
Hyperpigmentation (-), tumor (-), Hiperpigmentasi (-), tumor (-),
inflammation (-), spider nevi (-), inflammation (-), spider nevi (-),
Hemithorax D=S, ICS Normal, Hemithorax D=S, ICS Normal,
Diameter AP < LL Diameter AP < LL
DINAMYC The movement of hemitorax The movement of hemitorax
D=S, abdominothorakal D=S, abdominothorakal
breathing (-), muscle retraction breathing (-), muscle retraction of
of breathing (-), retraction ICS (-) breathing (-), retraction ICS (-)
PALPATION
Palpation pain (-), tumor (-), Palpation pain (-), tumor (-),
enlargement of ICS (-), enlargement of ICS (-),
Stem fremitus D=S Sterm fremitus D=S

PERCUTION
Sonor +/+ Sonor +/+

AUSCULTATION
ronchi (-) , wheezing (-) , ronchi (-) , wheezing (-) ,
vesikuler (+) D=S vesikuler (+) D=S
 THORAX - COR
INSPECTION
Unseen Ictus Cordis
PALPATION
Ictus cordis is palpable at ICS V, 2 cm lateraly from left mid clavicula line, thrill
(-)
PERCUTION

Upper borderline : ICS II left sternal line

Waist : ICS III left parasternal line
Lower right borderline : ICS V right parasternal line
Lower left borderline : ICS V front axilla line

AUSCULTATION
S1 & S2 (+), Additional sound (-),
 Abdomen
1.Inspection convex of surface(+), sycatric(-), striae(-), enlargement of
vena (-), caput medusa (-)

2.Auskultasi peristaltic (12x/minutes), aorta abdominal bruit (-), A.

Lienalis, A. femoralis (-)
3. percussion tympanic all abdominal surface,
Liver span : dex = 12cm ; sinistra = 6cm, area troube (+)
4. palpation mass (-), pain (-) , hepatomegali (-), Spleenomegali (-)
Murphys sign (-)
 Extremity

Ekstremity Superior Inferior

Oedem -/- -/-
Cold extremities -/- -/-
Physiological Reflect +/+ +/+
Ikteric -/- -/-
Impression Normal
 Laboratory Examination
01 February 2015
Result unit Normal Value

Haemoglobin 8,1 g/dl 11,5 15,5

Hematocrite 25,5 % 33 45

Leukocyte 12,9 thousand/uL 3,6 11,0

Platelet 436 thousand/uL 150 440

Blood type / Rh A/+

 result value

Blood Sugar 176 mg/dl 75-110 mg/dl

Quality HBsAg Non-reactive Non-reactive

 Result Normal Value
Blood Chemical
Ureum 57 mg/dl H 10-50 g/dl
Blood Creatinin 3,54 mg/dl H 0,5-0,9 mg/dl
Natrium 136,3 mmol/L 135-147 mmol/L
Kalium 4,73 mmol/L 3,5-5 mmol/L
Chloride 114,9 mmol/L H 95-105 mmol/L
 Laboratory Examination
03 February 2015
Result unit Normal Value

Haemoglobin 10,3 g/dl 11,5 15,5

Hematocrite 31,1 % 33 45

Leukocyte 12,4 thousand/uL 3,6 11,0

Platelet 342 thousand/uL 150 440

Blood type / Rh A/+

 Abnormality Data

Laboratoric
History Taking : Physical Examination:
Nausea Examination: 1. Low Hb 8,4
Vomiting Dry Skin 2. Low Ht
Headache Pale 3. High Ureum
Weakness 4. High Creatinin
Pale 5. High Chloride

PROBLEM LIST
1. Chronic Kidney Disease
 Chronic Kidney Disease
Ass : 3rd Grade CKD
IP Dx : Ureum, Creatinin, Blood Test, Electrolite (Na, K), Kidney Function Test
Ip Rx :
Non Pharmacologic
Low Protein Consumption
Pharmacologic
R/ Amlodipin 5mg 1x1
R/ Valsartan 80 mg 1x1
R/ Ondancetron 4mg 3x1
R/ Omeprazol 2x1
R/ Renal Protector 2x1
IP.Mx : Blood Test, Ureum, Creatinin
Calories needed

IW = (TB-100)-10%XBB
(155 100)-10%.50 = 50
( weight 50 normo)
50x 25 = 1250 kal / day
Age > 40 = -5%
Activity mild = +10%
Metabolic stress = +20%
TOTAL = 1250 + (25%.1250) = 1250 + 312,5 = 1562,5
Patient with DM & CKD
1562,5 breakfast 25%, lunch 30%, dinner 25%,
snacks between 2 big meals 10%. All portion of
dishes must contain less percentage of proteins
about 35g a day, less kalium, less phospat, and drink
limitation using last day urinating + IWL (500cc)

Conclusion :
Carbo 60%, protein (35g), fat (20%), no fruits, no
milk, no cocoa,