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Name : Mrs. W
Age : 50 years old
Address : Sembung, Sukorame- Lamongan
Admission : 7th June, 2017 14:27
Chief Complaint
Shortness of breath
Present history
DM denied
HT + since 3 years ego
Ever treated at hospital with same complains
Never dialysis
Family history
DM and HT denied
Social history
Pulse
92x/min
BP
139/87 mmHg
Temp
36.5C
RR
32x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 32x/min, ves / ves, rh + basah basal/-,
wh -/-, SaO2 91% without O2 support
C: extremity WDR, CRT <2, N 92x/min, TD 139/89
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36.5 C
GENERAL STATUS
General condition : looks weak
Awareness : compos mentis
GCS : 456
H/N : a -/i-/c-/d+ retraksi
intercostae, JVP increased R+2 90
THORAX
Inspection
Symmetrical, retraction +/+
Palpation
Fremitus (dbn), thrill (-)
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh + basah basal/-, wh -/-
Cor: S1 S2 single, mur -, gall-
ABDOMEN
Inspection
distended, collaterral veins (-), inflammation signs (-),
operation wound (-)
Auscultation
Abdomen sound + N
Palpation
Epigastric pain (-)
Liver/Spleen, renal is untouchable
Percussion
tymphany
EXTREMITIES
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)
Palpation
WDR, CRT <2 , leg pitting oedem +/+
CLUE AND CUE
Female 50th
Shortness of breath
Chest pain
Cough phlegm
Rh + basah basal /-
JVP increased R+2 90
Dyspneu with retraksi intercostae
Leg pitting oedem +/+
ASSESMENT
CKD
CHF
PLANNING DIAGNOSE
CKD
IHD
Pleural Effusion Dextra
Anemia
PLANNING THERAPY
O2 NRM 10 lpm SpO2 91 % 100 % , RR 32 26
Inf. PZ life line
DK residu 50 cc
Inj Lasik 2 amp
Inj Ceftriaxone 2x1 gr
Ca Glukonas 1 amp + D40 % + Novorapid 2 IU
3 times
Transfusion PRC 1 kolf/day
PO Kelitage 3dd I scht
PLANNING MONITORING
Vital Signs
Patients complaint
PLANNING EDUCATION