Case Dr Irwin-gita

8/3/2019 Case Dr Irwin-gita

1/26

Anggita Nur Aziza

030.07.019


2/26

y Name : Mrs. A

y Age : 30 years old

y Gender : Female

y Religion : Islam

y Work : House wife

y Status : Married

y Address : Istana Kosambi 76/20, Kampung

Duren RT 76 RW 20, kec.Klari,

Kab.Karawang

y Date of Admission : November 3rd ,2011

y Taken from : Rengasdengklok


3/26

Pain in all part of abdomen since 1 weekbefore hospitalized


4/26


5/26

y The presents patient condition started 3 months before being admitted to the

hospital. Her major complaint was pain in right lower abdomen that spread to

all of her abdomen. It felt tightness especially in right lower and middle lower

abdomen, get worsened when she eat and urinate. 2 years ago patient also

admit that she felt pain when shes urinating, it felt like prod no tingling,not

burning, still smooth no dripping when shes urinating. During that 3 months,

she always feel thirsty but her miction is a little amount, 7x times/day, total

2 aqua glass/day, the color is clear yellow, white yellowness stone came out

twice and fresh blood a half of aqua glass in her urine. 1 week before

hospitalized, she felt tightness after urinating again and white yellowness in its

color, and 3 days before hospitalized, its color changed to white nodes.


6/26

y Patient felt more easily tired and she complained about nausea,

vomitting sice 3 months ago more than 3 times/days as much as

1 aqua glass, contain food, and fluid without blood. She also felt

shortness of breath, since 3 days before hospitalized and she

hasnt been defecated for 2 days.

y She lost her appetite, weight is decrease 10 kg in past 4

months.

y She had no fever, dizziness, cough, chest pain, no sore in back

waist and no swelling of the leg.y Since 3 days before hospitalized her complaint is not getting

better, so she went to RSUD Karawang.


7/26

y The patient had felt the same symptoms

before she was hospitalized.

y She had no history of hypertension,

diabetes mellitus, allergy (medication or

food), liver, and cardiovascular.


8/26

Same illness with the patient (-)

DM (-) Hypertension (-)

Asthma / Allergic (-)

Cardiovascular / pulmonary disease (-)


9/26

She didnt exercise regularly

No Smoking

No drink alcohol No blood transfusion

Never consume herbal medicine

She used to consume emping, jeroan, jamu, tea

for 10 years

She rarely drink mineral water, only 2 glass/day


10/26

Moderately illGeneralconditionGeneralcondition

Compos mentisConciousnessConciousness

155 cmHeightHeight

30 kgWeightWeight

12.49BMIBMI


11/26

BP:

100/70 mmHg

HR:

88 x/min

RR:

20 x/min:

Temp:

36.00 c

VITALSIGN


12/26

y Head

Normocephaly

y Eyes

Conjunctiva anemic -/-

Sclera icteric -/-

Pupil isokor, DLR +/+, UDLR +/+

y Ears

Normotia, secrete -/-, serumen -/-

y Nose

septum deviation (-), secrete -/-, concha is normal

y Mouth

dirty mouth (-), dry mouth (-), dirty tongue (-), normal papil, mucosa not hyperemic, teeth

caries (-)

y Throat

Tonsils T1/T1 calm, pharynx hyperemic (-)

y Neck

Lymph gland is not palpable

Thyroid gland is not palpable

JVP 5+2 cmH2O


13/26

HEART EXAMINATION LUNG EXAMINATION

y Inspection:

Ictus cordis is invisible

y Palpation:

Ictus cordis is palpable at 5th ICS

LMCS

y Percution:

No enlargement of the heart

y Auscultation:

Regular I - II heart sound no

murmur and gallop

y Inspection:

Symmetrical

y Palpation:

Equal vocal fremitus

y Percusion:

Sonor in both lung

y Auscultation:

Vesicular breath sound in both

lung, no ronchi and wheezing


14/26

Inspection

distended, brown skin, skin abnormality(-)

Palpation

Tenderness(+) in all of her abdomen Tense in all of her abdomen

Hepatomegali (-), splenomegali (-)

CVA (-), ballotement (-)

Percussion

Tymphani , Shifting dullness (-)

Auscultation

Bowel sound (+) normal


15/26

y Warm acrals

y Oedem

+ +

+ +

- -

- -


16/26

BNOBNO

y Radio opaque atsupra simfisis


17/26

November 2nd

2011Patient result Normal range

Hb 10,5 g % 12 17 g%

Leukocyte 17.500/uL 5000-10.000/uL

Trombocyte 478.000 150.000-450.000Ht 33 % 37-48 %

GDS/reduction 128 mg/dl 80-140 mg/dl

Ureum 127,8 mg/dl 10-45 mg/dl

Creatinin 5,31 mg/dl 0.4-1.5 mg/dl

GFR(140 age) x weight x 0,85 (140 30) x 30 x 0,85

72 x plasma creatinin 72 x 5,31

= 7.33 ml/minute


18/26

Laboratory ExaminationLaboratory Examination(2(2))November 2nd

2011Patient result Normal range

HBsAg -

Anti HBs -


19/26

November 2nd 2011 Patient result Normal range

Color yellow

Turbidity +

Protein ++

Reduction -

Ephitelial +

Leukocytes

Erythrocytes 10-20

Crystal -

Cylinder -

Bacteria -


20/26

Symptoms Signs Laboratory and others

Pain in all of abdomensince 1 week beforehospitalizedPain when urinate, feltlike prod, always feelthirsty, miction littleamount, the color is

clear yellow, whiteyellowness stone, freshblood aqua glass,the color changed towhite nodesFatigue

NauseaVomittingShortness of breathLoss of appetiteWeght decrease

Vital Signs :BP : 100/70 mmHgHR : 88x/mRR : 20x/mT : 36.0 0 c

Distended abdomenTenderness (+) and

tense in all of abdomen

Hb : 10.5 mmHgLeukocyte : 17.500Thrombocyte :478.000Ht : 33Ureum :127.8Creatinin : 5.31Protein : ++Sedimen leukosit Sedimen eritrosit 10-20

GFR :7.33 ml/minute

BNO : radio opague insuprasimfisi


21/26

y Chronic kidney disease grade V ec

Vesicolithiasis

y Chronic kidney disease ec chronic

pyelonefritic

y

Chronic kidney disease ec GN chronicy Acute kidney injury


22/26

y Chronic kidney disease grade V ec

Vesicolithiasis


23/26

y Thoraks X-Ray

y BNO-IVP

y Ultrasound

y Renogram

y Stone analysis


24/26

y Bed rest

y Protein diet 18 gr/days

y D5% 20 dpm i.v

y Renxamin 1 fly Tramadol 2x1 amp

y Cefoperazol 2x1 amp

y Lasix 1x1 amp

y Folic acid 3x1 tab

y Ketosteril 3x1 tab

y Neurodex 3x1 tab

y Laxadin 1x1


25/26

Ad vitam: Dubia ad bonam

Ad Fungsionam: Dubia ad bonam

Ad Sanasionam : Dubia ad bonam


26/26

THANK YOU

Case Dr Irwin-gita

Documents