cbd st romanah

7/28/2019 CBD St Romanah

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PATIENT IDENTITY

Name : Mrs. SRAge : 54 years old

Gender : female

Religion : Moslem

Address : Banyumanik Semarang

Room : Baitul Izzah 1 (411.1)

Check in date : 15 MAY 2013

Check out date : 20 MAY 2013


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HISTORY TAKING

Patients had major complaints abdominal bloating. Said her stomachenlarges slowly on all parts of the abdomen since 1 month beforeentering the hospital. His stomach felt increasingly enlarged andincreased tension, but this enlarged abdominal complaints not to make

the patient tightness and difficulty breathing. The patient also complained ofpain in the epigastrium since 1 monthbut damning since 3 days before entering the hospital. Pain in theepigastrium is like prickling and constantly felt by the patient throughoutthe day. The complaint does not say improved or worsened by food.

Pain was also accompanied by complaints intermittent nausea that isfelt but is felt throughout the day, and vomiting usually occurs after a

meal. Vomit contains food or drinks are eaten previously, with a volumeof approximately cup aqua, but no blood. Complaint nausea andvomiting is to make patients become reluctant to eat (no appetite).

Patients also complain of fatigue since 2 weeks before entering thehospital. Perceived weak complaint said continuous and does notdisappear even patient has rested. This complaint is said to be felt in all

parts of the body and increasingly become heavy from day to day until 6days before admission patients can not perform daily activities.

Oedem


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HISTORY TAKING

In addition, patients also complain ofswelling in both feet andhand since 1 month before entering the hospital which madewalking difficult patients. Swelling said to be neither increasednor diminished when worn walking or rested. Complaints of legswelling is not accompanied by pain and redness. Denied ahistory of trauma to the foot of the patient.

The patient said that the defecate is normal, with frequency of 1-2 times per day. Micsi is like tea colour. Pain when urinatingdenied by the patient.

History of skin yellowing of the patient's body denied. Finally, thepatient feels restless and disturbed sleep at night. Complaintsbody heat, hair loss and bleeding gums denied by the patient.

Oedem


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HISTORY TAKING

Hypertension (-) Liver disease (-)

Kidney disease (-)

Diabetes mellitus (-)

Heart disease (-)

History of previous illness

Fathers patient had died because of a heartdisease

Family history of disease

Status of patient is general. Patients Economic is

average.

Social economic history


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Systemic Anamnesis


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PHYSICAL EXAMINATION dyspneu (-)General

Compos mentisAwareness

Weight = 87kg; Height = 170 cmNutrient state

BMI= BB(kg)/TB(m)= 87/(1,70)2 = 30,1 (obes)BMI

TD 130/80 mmHg

HR 84/menit

RR 20 X/m

T 36,5 C

Vital Sign

Mesocephal, alopesia (-)Head

Anemic Conjuntival (-/-), Jaundice Sclera(-/-)Eyes

Secret (-), Nostril Breath (-)Nose

Normal Shape, Discharge (-/-)Ears Hyperemic (-), Pain Devour (-)Throat

Cyanosis (-), Dry Lips (-),Mouth

Trachea Deviation (-), Lymph Hypertrophy (-)Neck

edema of upper and lower extremity (+)Extremity

Interpretation : prehypertension, edema of upper and lower extremity (+)


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THORAX - PULMONARY

INSPEKSI ANTERIOR POSTERIOR

Static RR : 20 x/min,Hiperpigmentation (-), spider

nevi (-), atrofi M. Pectoralis (-),

Hemithoraks S=D, ICS extend

(-), Diameter AP < LL

RR : 20 x/min, Hiperpigmentation(-), spider nevi (-), Hemithoraks

Hemithoraks S=D, ICS extend (-),

Diameter AP < LL

Dinamic Up and down of hemitoraksS=D, muscle retraction of

breathing (-), retraction ICS (-)

Up and down of hemitoraks S=D,muscle retraction of breathing (-),

retraction ICS (-)

Palpation Palpation pain (-), tumor (-),

enlargement of ICS (-), Stem

fremitus D=S

Palpation pain (-), tumor (-),

enlargement of ICS (-), Stem

fremitus D=SPercution sonor sonor

Auskultation Vesicular(+), ronchi (-),

wheezing (-)

Vesicular(+), ronchi (-), wheezing

(-)


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THORAX - COR

Inspection : Ictus cordis seen.

Palpation : Ictus cordis is palpable in ICS VII linea mid clavicula sinistra,thrill (-).

Percussion : dull sound

Upper borderline of heart : ICS II linea sternalis sinistra

Waist of heart : ICS III linea parasternalis sinistra

Lower right borderline of heart : ICS VI linea parasternalis dextra

Lower left borderline of heart : ICS VII 2 cm lateral linea mid

clavicula sinistra

Auscultation :

Aorta Valve : SD I-II pure, regular, AIT2

Pulmonal Valve : SD I-II pure, regular, P1M2

Addition Sound : (S3 -)

Interpretation : susp. cardiomegali


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ABDOMEN

Inspection : distention(+), cycatric(-), striae(-),

caput medusa (-). Auscultation : peristaltic (+) N

Percution : shifting dullness (+), traube space(-)

Palpation

Superficial : massa (-)

Deeper : abdominal pain (+), hepar & lien aredifficult to evaluate, renal isnt palpable

Interpretation: susp. Ascites, splenomegali


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Extremities

Extremities superior inferior

- edema +/+ +/+- cold extremity -/- -/-- reflect physiologist +/+ +/+

- Icteric -/- -/-


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LaboratoryFindings


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LABORATORY15-5-2013 Hematologi Normal

Hemoglobin 10,04 g/dl L 11,7-15,5mg/dl

Hematokrit 30,5% L 33-45%Leukosit 13,06 3/uL H 3,6-11rb/ulTrombosit 603/Ul L 150-

440rb/ul

Eosinofil % 0,3% L 1-3Basofil % 0,4 % 0-1

Neutrofil % 68,4 % 50-70

Limfosit % 17,4 %L 25-40Monosit % 13,5 % H 2-8LED 1 48 H 0-20mm/jamLED 2 73 H 0-20mm/jam

Golongan darah/Rh O/+


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15-5-2013 KIMIA Normal

Ureum 35 10-50mg/dl

Creatinin 1,03H 0,5-0,9mg/dlSGOT 59 H UISGPT 39 H UI

HbSAg kualitatif (-)


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16-5-2013 Urin lengkap Normal

warna Kuning

Kejernihan Agak keruhProtein (-)


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16-5-2013 Urin lengkap Normal

Mikroskopis

Epitel sel 3-4 5-15/LPK

Eritrosit 10-12H 0-1/LPBLeukosit 15-20H 3-5/LPBSilinder (-) 0-1(Hialin)/LPK

Parasit (-) (-)Bakteri (-) (-)

Jamur (-) (-)

Kristal (-)

Benang mukus (-)


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16-5-2013 Kimia NORMAL

GD2PP 207 mg/dlH < 120mg/dlGDP 114H 74-106mg/dlCholesterol 82


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EKG


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INTERPRETATION

1. Rhythm : Iregular

2. Heart Rate : -

3. Axis : Lead I (+) ; AVF (+)Normo Axis Deviation4. Zona Transisi : V3

5. Morphology :

- P wave : Normal (0.12 sec)

- Interval PR : Normal (0,12 - 0,16 sec)

- QRS complex : VES (>0.12 sec)

- ST segment : isoelektris

- T wave : Inverted (-)T tall (-)

- Interpretation : VES benigna (aVR)


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RADIOLOGY

Susp.Cardio

megali


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Interpretation

Thorax X-ray examination

CTR can not be assessed, apex

shifted to laterokaudal (suspectedcardiomegaly)

Pulmo: image of vascular normal,

no visible spots on both lungsRight diaphragm as high as 8

posterior costa, both costophrenic

sinus


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USG ABDOMEN


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Interpretation

Overview of the process of chronic

liver with mild splenomegaly liver

cirrhosis suspiciousYet signs of portal hypertension

Kidney and pancreas within normallimits

Ascites

Ab lit D t


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Abnormalitas Data

Anamnesis

1. Abdominal bloating

2. Pain in the epigastrium

3. Nausea

4. Vomit

5. Micsi like tea 6. Fatigue

7. Oedem extremity

Physic Examination :

8. obesity

9. Prehipertension

10. edema of upper and lower

extremity11. susp. Cardiomegali

12. Distention(+)

13. Shifting dullness (+)

14. Traube space (-)

15.Abdominal pain (+)

Advance Examination:16. Anemia

17. Leukositosis

18. Trombositopenia

19. Eosinofil (L)

20. Limfosit (L)

21. Monosit (H)

22. LED 1/2 (H)

23. Creatinin (H)

24. SGOT & SGPT (H)

25. Urin : berat jenis (L)

26. Hematuria

27. Leukosit urine (H)

28. Hiperglikemia

29. Hipoalbuminemia

30.VES31. Ro thorax : susp kardiomegali

32. USG Abdomen : splenomegali, suspsirosis hepatic, ascites


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PROBLEM LIST

Asites Sirosis hepatis CHF Hiperglikemia Hipoalbuminemia


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Asites Abdominalbloating Distention(+) Shifting dullness(+) Leukositosis Hipoalbuminemia

USG Abdomen :ascites


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Sirosis hepatis Pain in theepigastrium Nausea Vomit Micsi like tea Fatigue Traube space (-) Abdominal pain(+) Anemia

Trombositopenia LED 1/2 (H) SGOT & SGPT (H) Hipoalbuminemia USG Abdomen :splenomegali,susp sirosishepatic, asites


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CHF Abdominal bloating Fatigue Oedem extremity edema of upper andlower extremity susp. Cardiomegali Distention(+) Shifting dullness (+) Ro thorax : suspkardiomegali


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Hiperglikemia GDS (H)

GD2PP (H)

GDP (H)


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HipoalbuminemiaAlbumin (L)


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Ass

IP Dx

IP TxIP Mx

IP Mx


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Ass transudat, eksudat Ip Dx : px. SAAG ( Serum Acites Albumin Gradient)

Non Farmakology : Diet enough salt 2 gram/ dayDiit low liquid 1 liter/ day

Farmakology : inj Furosemid 3 X 10 mg/ml

spironolacton 3 X 100mg tab

Ip Mx : Darah rutin , chemistry blood ( ureum, creatinin, albumin,globulin, totalprotein),

Ip Ex : bed rest, reduce dringking and salt


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Ass : Kompensata, Dekompensata IP Dx : Biopsi hati Ip Tx :

Non Farmacology Bed rest

Farmacologyinj cefotaxime 2 x1

Curcuma 2 x 1 Ip Mx : SGPT, SGOT, albumin, routine blood, HBsAg Ip Ex : eating from hospital, bed rest


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Assessment : Anatomi diagnosis(LVH,LAH)Etiologi diagnosis

(HHD,IHD), Cardiomiopaty, LV Fraksiejection

Dislipidemia

IP. Dx : Echocardiography LVEF

IP. Rx : Non Farmacology :

Bed Rest

of sit down position

Drink water < 1,5-2 l/day(especially in patient hyponatremia) Diet High Kalori low Protein lowsalt )

Farmacology

O2 2-3 L/minutes

Digoxin (2x1/2tab)

Spironolakton 1x 25 mg

Inj Furosemid 3 x 1 amp

ISDN 3x 5 mg

IP. Mx : Vital Sign, Fluid Balanced, Electrolit lab,Electrocardiography

IP. Ex :diet low salt and low protein Eat and drink as ruled of hospital

Use canul O2 if the patient feel short breathness No drink alcohol, coffee, no cigarrete

Mild Exercise 30 minutes everyday

use drug as treatment reguarly


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Assessment :DM type I, DM type II, Another DM IP. Dx : HbA1c IP. RX

Non Farmacology

Diet low glucose Increase Physical exercise

Educating about Diabetes Mellitus

Farmacology : OHO, Insulin Injection

IP. Mx : General Condition, GDS, GDP, GD2PP IP. EX :

Needed controlling and examination for DM

Diminished intake high carbohydrate and fatty

Do the mild exercise and moderate regulary


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Ass: albuminuria

IP Dx :

IP Tx : transfusi albumin

perhitungan albumin = (3,5

Kadar albumin) x 0,8xBB =(3,5 -2,08)x 0,8 x 87kg = 98,8

4 albumin x25 % 100 cc

Sediaan dipasaran20 % 100 cc, 25 % 100 cc, 20 %50 cc, 25 % 50 cc 25 % 50 cc

IPMonitoring : replay albumin test everyday


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Follow UpDate BP HR RR T GDS S O A P

15.5.2

013

130

8084x 20x

36,5

oC201

Oedem ofUpper and

lower

extremities,

abdominal

bloating,

nausea,

vomit, pain in

epigastrium,

fatigue

prehypertension,

ascites,

hiperglikemi

ECG,RO Thorax,

USG Abdomen,

salt, Diet low

glucose

16.5.2

013

130

80 84x 24x36

oC205

Oedem of

Upper and

lower

extremities,

abdominal

bloating,

fatigue

prehypertension,

ascites,

hiperglikemi

salt, Diet low

glucose

.

17.5.2

013

150

8092x 20x

36,4

oC

Oedem of

Upper and

lower

extremities,

abdominal

bloating,

fatigue,

headache

Hypertension

grade I, ascites

salt, Diet low

glucose

.

Follow Up


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Follow UpDate BP HR RR T GDS S O A P

18.5.2013

14090

62x 20x

36,5oC

118

Oedem of

Upper and

lower

extremities,abdominal

bloating,

fatigue,

headache

Hypertensio

n grade I,

ascites,

hiperglikemi

salt, Diet lowglucose

.

19.5.2

013

130

8078x

22

x

36,5

oC

Decrease

Oedem of

Upper andlower

extremities,

decrease

abdominal

bloating,

fatigue

prehyperten

sion,

ascites

salt, Diet low

glucose

.

20.5.2

013

130

8076x

18

x

36,5

oCfatigue prehyperten

sion

salt, Diet low

glucose

.


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BB : 87 kg

TB : 170 cm

Aktivitas : istirahat

BBI = (TB-100) x 1kg= (170 -100) x 1kg

= 70 kg

Status Gizi = (BB : BBI) x 100%

= (87 : 70 ) x 100%

= 124%

Calori Basal = BBI x 25 Calori/kg

= 70 x 25 Calori /kg

= 1750 Calori/kg

KoreksiUmur 40 59 year (-5%) = - 87,5 calori

Aktivitas istirahat (+10%) = + 175 calori

Obesity (-20%) = - 350 calori

Total = 1487,5 kalori 1450 calori

HITUNG

KALORI


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Terima KasihWassalaamu'alaykum Wr.Wb.

cbd st romanah

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