Cbd Dr Saugi
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ADVISERDR. H. M. SAUGI ABDUH, SP.PD
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PATIENTS IDENTITY
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Patient came to IGD with chief
complaint was vomitus since 1 day
ago. Patient had vomit 12 times. Shealso felt malaise, dizziness,
jaundice, subfebrile, nausea,
decrease in appetite and the colour
of urine was dranker. She felt this
complaints after she drank drug from
her first be inpatient
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Socio-economic history:
Medical expenses incurred by Jamkesmas
Familys history of disease
- The same symptomps (-)
- TB pulmo (-)
Previous history illness- TB pulmo (+)
- Hypertension (-)
Diabetes mellitus (-)
- Asma (-)- Allergy (-)
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SYSTEMIC ANAMNESIS
General : weakness
Skin : itching (-), jaundice (-), pale (-), slick (-)
Head : headache (-)
Eyes : blurred vision (-), red eyes (-/-), icteric sclera (+/+)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
Neck : enlargement of the gland (-)
Chest : cough (+), sputum (-), blood (-)Cardiac : chest pain (-), palpitations (-)
Digestive : decreased appetite(+), nausea (+), vomiting (+), defecate /
micsi (+/+), urine colour is darker
Musculoskeletal : weak (+), rigid (-), back pain (-)Extremit : oedem extremit -
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PHYSICAL EXAMINATION
General Status
General : weakness
Awareness : composmentis
Vital Sign
Blood Pressure : 100/70 mmHg
Heart rate : frequ. 76x/minutes, regural ritmict, strong
amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-)
Breath Frequency : 24x/minutes
Temp : 36,5o C
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntiva(-/-), Icteric sclera(+/+)
Nose : symmetric, secret (-), Nostril Breath (-) Ears : Normal Shape, discharge (-/-)
Esophagus : Hyperemic (-), pain devour (-)
Mouth : Cyanosis (-), dry lips (-),
Neck : Trakhea deviation (-), Lymph Hypertropy (-)
Extremity : Oedem of lower extremity (-), Oedem of upper extremity (-)
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THORAX-LUNG
INSPEKSI ANTERIOR POSTERIORStatic RR : 24x/min, Hyperpigmentation (-),
spider nevi (-), atrofi M. Pectoralis (-),
Hemithoraks D=S, ICS Normal,
Diameter AP < LL
RR : 24x/min, Hiperpigmentasi (-),
spider nevi (-), Hemithoraks D=S,
ICS Normal, Diameter AP < LL
Dinamic Up and down of hemitoraks D=S,abdominothorakal breathing, (-),
muscle retraction of breathing (-),
retraction ICS (-)
Up and down of hemitoraks D=S,
abdominothorakal breathing (-),
muscle retraction of breathing (-),
retraction ICS (-)
Palpation Palpation pain (-), tumor (-),enlargement of ICS (-), Stem fremitus
S=DPalpation pain (-), tumor (-),
enlargement of ICS (-), Stem
fremitus S=D
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Percution Sinistra : redupDextra : upper : redup; lower : sonor
Sinistra : redup
Dextra : upper : redup; lower :
sonor
Auskultati
on ronchi (+) S>D, wheezing (-) ronchi (+), S>D wheezing (-)
Interpretation: ronki +,
percussion redup infiltrat
on both lung (S>D)
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CARDIAC
Inspection Ictus cordis isnt seen
Palpation Ictus cordis is palpable in ICS V 2 cm medial from linea mid
clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsuspara-sternal (-), sternal lift (-)
Percussion Upper borderline : ICS II linea sternalis sinistra
Waist : ICS III linea parasternalis sinistra
Lower right borderline : ICS V linea sternalis dextra
Lower left borderline : ICS V 2 cm medial linea midclavicula
sinistra
Auscultation Aorta valve : S1 & S2 standart, additional sound (-), AIM2
Interpretation: normal
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INSPEKSI
Symetric, sycatric(-), striae(-), scuama(-) enlargement of vena (-), hyperpigmentasi
(-), spider nevi (-)PALPATION
peristaltic (+) Normal (24 x/ minutes)
PERCUTION
side of deaf (-), shiftingdullness (-), undulation(-)
Hepar : deaf(+), liver span dextra 7 cm, liver span
sinistra 5 cm
Lien : traube space perkusi dull sound
AUSKULTATION
Superfisial :
massa (-), abdominal pain (-)
Deeper:
abdominal pain (+), hypocondrium dextra andepygastriumhepar is not palpable, lien is not palpable, kidneyis not palpable.
Interpretation: There are a process in
hypocondrium and epygastrium
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EXTREMITY
11
Ekstremity Superior InferiorOedem -/- -/-
Cold akral -/- -/-
Fisiologis reflect +/+ +/+
Interpretation: normal
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16 May
2012
19 May
2012
Normal value
Hematologi
- Hemoglobin- Hematokrit- Leukosit-
Trombosit
14,4
45,4
10,9
529
11,7-15,5 g/dL
33-45%
3,6-11 ribu/uL
150-440 ribu/uL
Kimia
- Bilirubin total- Bilirubin direk- Bilirubin
indirek- SGOT- SGPT
15,57
11,27
4,3
53
180
9,71
7,33
2,38
31
95
0,1-1,0
0-0,2
0-0,75
0-35
0-35
Imunoserologi
- HBsAg kualitatif Negative Negative
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BTA sputumSewaktu I (+) 2
Pagi (+) 2
Sewaktu 2 (+) 2
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18
Interpretasi :
normal
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INTERPRETATION
Interpretation: Cor : CPR
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Vomitus, nausea
Malaise, dizziness Subfebrile
Jaundice
Decrease in appetite
Colour of urine isdranker
Anamnesa
Weakness
Icteric sclera
Percussion lung : redupS>D
Ronchi (+) both of lungS>D
Abdominal pain(hypocondrium dexand epygastrium)
Physicalexamination
Hiperbilirubinemia
Increase liver enzym
TB pulmo
X-photo thorax :cloudiness both of lung
S>D; calsification hiluslymp
Advance
examination
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PROBLEM LIST
Hyperbilirubinemia with
jaundiceTB pulmo
Dyspepsia
HYPERBILIRUBINEMIA
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HYPERBILIRUBINEMIA
WITH JAUNDICE
Ass :
o Intrahepatic (viral hepatitis, hepatitis drug induced) or post hepatic(kolesistitis, kolelithiasis, pankreatitis, pankreas cancer)
Ip. Dx :
o Imunoserology viral hepatitis; liver function test; amylase serum,
ptotrombin time post giving vit K; USG Ip. Tx :
Therapy based on the etiology
Ip. Mx :
Bilirubin concentration, jaundice, liver function test Ip. Ex :
o Explain the cause of her complaint
o Bed rest
o Drink drug regularly
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Ip. Mx
Bilirubin serum, alanin and aspartat aminotransferase
concentration, albumin serum, fosfatase alkali
concentration
Ip. Ex :
Explain about her disease
Stop this firs inpatient drug if she gets complaints like
them and consuls to the doctor
Improvement of food and beverage hygieni
Improvement of environmental
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TBC
Ass Ip. Dx:
Ip. TxOATs First Category.
Ip. MxBTA sputum, Chest X-Ray
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IP Ex
Explain about his diseaseDrink Drugs regularlyExplain side effect of drugsThe way of transmission close the mouth when
get cough, where put the pleghm, and keep infamily condition.
Increase the good lifestyleSTOP smoking
Open the window and warm the bed on under shiningsun day regularly
Control to doctor regularly
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DYSPEPSIA
Ass :
Organic or functional dyspepsia
Ip. Dx :
Endoscopy, abdomen USG
Ip. Tx :
Inj. Pantoprazole 1A/day
Po : antacyd liquid 3x1C
Ip. Mx :
The complaint
Ip. Ex :
Avoid spicy and sour food
Avoid stress
Eating on time
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