1.

Kisman , Male 39 yo,HCU 11

Cc : decrease of conciousness since 1 day ago

Present Illness history :
decrease of conciousness sice 1 day ago,
nausea since 5 days ago, vomit (+) content
food , bloody vomit (-)
decrease of apetite (+) since 5 days ago
patient has been hospitalized in RSUD painan
for 3 days and diagnosed with CKD stage V and
has tranfution 4 unit. patient was refered to
M.Djamil hospital caused by decrease of
conciousness.

2
- breathelessness since 2 days ago, no influence
with activity, weather and food.


past illness history ;
- history of hypertention not known
- history of chest pain not known
- history of diabetes not known



Physical Examination
consc :delirium GA : bad

BP: 160/90 mmHg HR: 104x/
RR: 40x/ T:37,2
0
C

Eye : anemic (+)/(+), icteric (-)
neck : JVP 5+0 cmH2O
Lymp nodes: no enlargment
Lung: normochest,simetris,sonor,
bronkovesikuler, rales (+/+), wh (-/-)
Heart: ictus unseen,ictus was palpable at RIC VI 1
finger lateral LMCS ,regular rhtym, gallop(-)


5/20/2014

abdomen : flat ,hepar and lien was not
palpable, tympani, bowel sound (+)

extremity : RF +/+, RP -/-, edema +/+





LABOR

Hb : 6,6 gr.dl
Ht : 20%
leukosit : 10.700/mm3
trombosit : 187.000/mm3

GDS : 153 mg/dl
ureum /creatinin : 299/15,9 mg /dl

TKK : 5,2

protein urine : +++ (3)



5/20/2014
working diagnose :
CKD stage V ec nefroskelorosis hypertention
with uremic ensefalopathy and asidosis
metabolic
dd/: CKD stage V ec PNC
. CHF fc II LVH RVH sinus tacikardi rhytm ec
HHD
. hyponatremia ec hemodilution
dd/ : hyponatremia ec low intake
5/20/2014
therapy:
rest/ NGT diet/ MC DJ II / O2 3 liter / i
IVFD Nacl 3% 12 hours/kolf ( 2 kolf)
IVFD easprimer 500 cc/24 hours
inj ca glukonas 1x1 ampul (extra)
inj. lasix 1x1 ampul
asam folat 1x 5 mg
bicnat 3x500 mg
corection meylon 200 meq in 200 cc Nacl 0,9
% rapid tears
crossmatch
tranfution PRC 1 unit post lasix
5/20/2014
PLAN
consult to ophtalmologist
exp.rontgen thorax
check hepatitis marker
check faal hepar
echocardiography
1. Wirman Wahid , Male 66 yo,HCU 7
Cc : breathlessness increase since 1 day ago

Present Illness history :
breathlesness increase since 1 day ago, it has been felt since 5
days ago, no influence with activity, weather and food.
patient has been known CKD and has been undergone hemodialisa
since 8 months ago every tuesday and thursday
cough since 5 days ago, sputum (+)
fever since 1 day ago, not high, not chill, and not sweat a lot
decrease of apetite since 5 days ago.
history of sleep with 2 pillows (+)


10


- swollen at both of legs (+) since 2 weeks
ago

- defecation and mixturition normally

- history of diabetes melitus (+) since 34
years ago, uncontrolled regularly.

- history of hypertention (+) since 32 years
ago, uncontrolled regularly.



Physical Examination
consc :CMC GA : moderate

BP: 190/100 mmHg
HR: 88x/
RR: 22x/
T:37
0
C

Eye : anemic (+)/(+), icteric (-)
neck : JVP 5+1 cmH2O
Lymp nodes: no enlargment
Lung: normochest,simetris,sonor,
bronkovesikuler, rales (+/+), wh (-/-)
Heart: ictus unseen,ictus was palpable 1 finger lateral
LMCS RIC VI,regular rhtym,gallop(-)


5/20/2014

abdomen : hepar was palpable 1 finger bac,
blunt edge, flat, pain (-), lien S0
tympani, bowel sound (+)

extremity : RF +/+, RP -/-, edema +/+





LABOR

Hb : 9,5 gr.dl
Ht : 29%
leukosit : 6.200/mm3
trombosit : 141.000/mm3

Na : 137 mmol/l
kalium : 3,9 mmol/l
clorida : 103 mmol/l

GDS : 85 mg/dl
ureum /creatinin : 85/7,2 mg /dl

TKK : 8,5



5/20/2014
working diagnose :
CHF fc III LVH RVH sinus rhytm ec ASHD
CKD stage V ec nefropati diabetikum on HD
routine
bronkopnemonia duplex (CAP)

DD/
CHF fc II LVH RVH sinus rhtym ec HHD
susp. lung TB duplex
5/20/2014
therapy:

rest/ DJ II RP 45 gram DD 1700 kkal
IVFD easprimer 500 cc/24 hours
inj. lasix 1x1 ampul
inj. ceftriaxone 1x2 gram (iv) skin test
asam folat 1x 5 mg
bicnat 3x500 mg
ambroxol syrup 3xcth II
glurenorm 1x30 mg
amlodipin 1x10 m
candersartan 1x 8mg
catheter urine --> fluid balance
5/20/2014
PLAN

exp.rontgen thorax
echocardiography
hemodialisa
USG ginjal
zenko binter, Male 32 yo,petri
Cc : breathlessness increase since 1 day ago

Present Illness history :

breathlesness increase since 1 day ago, no influence with
activity, weather and food.
cough since 2 weeks ago sputum(+), blood (-)
fever since 2 weeks ago, high, chill (-), sweat (-)
decrease of body weight (+) since 2 months ago, but patient dont
know how much is
decrease of apetite since 2 weeks ago,




18


- history of sweat at night (+) since 2 weeks
ago
- candidiasis oral (+) since 2 weeks ago
- patient was refered to M.Djamil hospital
from RST bukittinggi, and has been
hospitalized for 7 months and has done
Rapid test HIV reaktif
- history of free sex (+) at 2013
- history of consumed narkoba drugs (-)
- tatoo (+)
- history of consumed OAT (-)
- history of DM (-)
- history Hypertention (-)
Physical Examination
consc :CMC GA : moderate

BP: 150/90 mmHg
HR: 120x/
RR: 40x/
T:38
0
C

Eye : anemic (+)/(+), icteric (-)
neck : JVP 5-2 cmH2O
Lymp nodes: no enlargment
Lung: simetris statis and dinamis, fremitus increase at right
lung, sonor, bronkovesikuler rh+/+, wh -/-

Heart: ictus unseen,ictus was palpable 1 finger medial
LMCS RIC V,regular rhtym,gallop(-)


5/20/2014

abdomen : hepar was palpable 2 finger bac,
blunt edge, flat, pain (-), lien S0
tympani, bowel sound (+)

extremity : RF +/+, RP -/-, edema -/-





LABOR

Hb : 6,9 gr.dl
Ht : 21%
leukosit : 21.400/mm3
trombosit : 309.000/mm3

GDS : 129 mg/dl
ureum /creatinin : 31/0,7 mg /dl

pH : 7,36
pCO2 : 42
pO2 : 35
HCO3-: 23,7
BEecf : -1,7
So2c : 64 %





5/20/2014
working diagnose :
sepsis ec bronkopnemonia duplex (HAP) with
respiratory failure type 1
IO with lung TB duplex + oral candidiasis
moderate anemia normositik normokrom ec
chronic disease
hiponatremia ec low intake
5/20/2014
therapy:

rest/ NGT diet MC TKTP/ sungkup NRM 10 l/i for 6 hours--> O2
5l/i
IVFD Nacl 0,9 % 6 hours/kolf
inj. meropenem 3x1 gram (iv) skin tes
cotrimoxazole 1x960 mg
fluconazole 1x150 mg
ambroxol syrup 3xcth II
paracetamol 3x500 mg
crossmatch
transfution PRC 1 unit untill >= 10 gr/dl
catheter urine --> fluid balance
5/20/2014
PLAN

exp.rontgen thorax
BTA I,II,III
blood culture
sputum VCT
ASMAR, Male 65 yo,PETRI
Cc : swolen at upper right stomach since 15 days ago

Present Illness history :

swolen at upper right stomach since 15 days ago, it has been felt
since 1 month ago and increase in this 2 weeks , sometimes
patient felt pain also,intermitent pain.
patient felt full faster than usual while eating since 15 days ago
decrease of body weight (+) about 5 kg in the last1 month
decrease of apetite (+) since 1 month ago
fatigue has been felt since 2 weeks ago
history of black stool (-), bloody vomit (-)


26


- fever (-)
- nausea (-), vomit (-)
-history of sleep disorder (-)
- history of hepatitis (-)
- history of drink alkohol (-)
- history of hypertention and diabetes (-)
- defecation and mixturition normally


family history illness:
his mother suffered ca. mamae


Physical Examination
consc :CMC GA : moderate

BP: 120/80 mmHg
HR: 100x/
RR: 20x/
T:37
0
C

Eye : anemic (-)/(-), icteric (-)
neck : JVP 5-2 cmH2O
Lymp nodes: no enlargment
Lung: normochest,simetris,sonor,
vesikuler, rales (-/-), wh (-/-)
Heart: ictus unseen,ictus was palpable 1 finger medial
LMCS RIC V,regular rhtym,gallop(-)


5/20/2014

abdomen : hepar was palpable 4 finger bac,
blunt edge, flat, pain (-), lien S0
tympani, bowel sound (+)
spider nevi (-)
kolateral (-)

extremity : RF +/+, RP -/-, edema -/, palmar
eritem (-)





LABOR

Hb : 12,7gr.dl
Ht : 40%
leukosit : 6.600/mm3
trombosit : 262.000/mm3


5/20/2014
working diagnose :
Hepatoma
5/20/2014
therapy:

rest/ DH II
IVFD aminofusin hepar : triofusin 1:2 8 hour/kolf
curcuma 3x1
sistenol 3x1 tab
5/20/2014
PLAN
.USG abdomen
. hepatitis marker
.