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RESIDENT ON DUTY:
- dr. FACHRULL
- dr. YULIANTO
COASS ON DUTY:
- ELSA
- OKI
Patient Recapitulation
Name :K
Age : 40 y.o
Sex : Female
Religion : Moslem
Address : East Jakarta
Marital Status : Married
Med. Rec. No : 826586
Anamnesis
Autonamnesis
Chief Complaint :
Shortness of breath for 2 weeks
History of Present Illness
Patient came to the ward with feeling
shortness of breath for 2 weeks. It was going
whole day and worsened by activity.
2 weeks before admission patient had done 8
haemodialysis at RS Sumedang, she was sent
to RSPAD due to limitation of the equipment.
3 months before admission: she complained
about nausea, vomit, shortness of breath, dry
cough and itchy skin on whole body. Those
complaint were getting worse each day and
she felt her stomach and feet were getting
swollen.
Her apetite within normal limit, she limits her
drinks 600 cc/day.
Defecate within normal limit, urinate 250
cc/day.
She had done HD before came to the ward.
Now, she felt sleep better with 2-3 pillows.
PND (-)
History of Past Illness
HT (+) since 5 years ago
DM (-), Heart Disease (-)
Family History
HT (+) her grandmother
Heart Disease (-), Kidney Disease (-)
Medication History
Amlodipin 1x10mg, not regularly
Physical Examination
General State : Moderatly Ill
Conciousness : Compos Mentis
Vital Sign
- BP : 140/120 mmHg - RR : 28 tpm
- HR: 112 bpm, Reg - T : 36,5oC
Body Weight : 50 Kg
Body Height : 155 Cm
BMI : 20,83 Kg/m2 (Normorweight)
Head : Normocephal
Eye : Anemic Conjunctiva +/+, Icteric
Sclera -/-
ENT : Within Normal Limit
Neck : JVP are unevaluable due to her pain
from the CDL, Lymph nodes enlargement (-)
Thorax
- Pulmo
I : Symmetry movement from both hemithorax
P : Vocal Fremitus within normal limit,
symmetry expansion from both hemithorax
P : Sonor
A : Vesicular +/+, Rales +/+, Wheezing -/-
- COR
I : Ictus Cordis was seen
P : Ictus Cordis was palpable on ICS V sinistra
midclavicula line
P : No cardiomegaly
A : Regular 1st and 2nd heart sound, Murmur (-),
gallop (-)
Abdomen:
- I : rounded abdomen
- A : Bowel Sound (+) within normal limit
- Pa : No organomegaly, skin turgor within
normal limit
- Pe : Shifting dullness (+), CVA tenderness -/-
Diabetic
Electrolyte Anemia
Acidosis Metabolic Thrombosis
Nutrition
Disturbance
Conservative
Management
Haemodyalisis
Haemodyalisis