30 Maret Huzaini ckd

8/18/2019 30 Maret Huzaini ckd

1/14

Summary of Data Base Mr. Huzaini / 53 yo /w.26 Anamnesis : Autoanamnesis Chief Complaint : Black tarry stool

•Patient suered from black tarry stool since 5 hours before

admission, blacktarrystool 4x about one glass of mineral

ater each, soft consistency, faulty odor, didn!t accom"anied

by fresh blood and mucus#

•$e also com"lained about %omiting, red colored, &x, '()

s"oonful, consisted of ater and food remains at 5 hours

before admission, ha""ened before black tarry stool#

•*ast year $e "erform ligation for treatment his bleeding#


2/14

• $e diagnosed $e"atitis + infection since ) years ago, and

routinely controlled at astro out"atient clinic at -SSA, $e

got *esichol 'x& and "ro"ranolol 'x& for the treatment

• Family History : $is "arents already "assed aay,

has . siblings, /o one in his family has history of 0aundice1

chronic li%er disease#

• Past Mei!al History : hos"itali2ed &) times ith the

same com"lained

• "o!ial history : $e as married, has 4 children#


3/14

Physical 3xamination

eneral a""earance: looked moderately ill +S 45 AS: 67&6

BP 8 &6676 mm$g P- 8 ' regular,strong

-- 8 &. t"m, 9ax : )#5 +

$ead Anemic con0uncti%a;P - < 6 cm$'? at )6˚ lym"hnode enlargement ;(=

+hest $eart: @ctus in%isible and "al"able at @+S & cm lateral, +* Sinistra

*ung: Stem remitus D8S S S -h ( ( Ch ( ( S S ( ( ( ( S S ( ( ( (

Abdomen and enital

-ectal 9oucher

at, soe, boel sound normal, e"igastric tenderness ;(=, li%ers"an . cm, 9raube!s s"ace : dullSphincter tonus (+), mucosa: smooth, sulcus medianus palpable, melena (+)

3xtremities

Erine out"ut

?edema ( @ (( @ (

'#5 cc7hrs


4/14

*aboratory inding, >uly th '6&5*ab alue *ab alue

*eukocyte &&,'F6 ),566(

&6,)667G*

/atrium &)6 &)(&45

mmol 7 *

$emoglobine+

F#66F5#.6

&(&#5g7dl.6(HF f*

Ialium 5#6) )#5(5#6 mmol 7*

+$ ''#66 '#5())#5

"g

+hlorida &&& H.(&6 mmol 7

*P+ '4#&6 )5(56J Albumin )#66 )#5(5#5 g7d*

9rombocyte .&,666 &46,666(4'4,6667G*

-BS &)4 K'66

3u7bas7/eu7*

y7o

6#676#&7FF#)7&#57#& J S?9 )F 6(4&E7*

Ereum .5#)6 &6(56mg7d*

SP9 '' 6(4&E7*

+reatinine && 6,F(&,5mg7d*


5/14

+L-, arc )6th '6&5


6/14

+L- @nter"retation

• AP "osition, asymmetric, enough I, lessins"iration

• Soft tissue and Bone normal

• 9rachea in the middle

• $emidia"hragm D and S ere dome sha"ed,• Phrenico costalis angle D and S ere shar"

• Pulmo D7S: @ncreased BP

• +or: site /ormal

+onclusion : normal +L-


7/14

3+, arch )6th '6&5


8/14

3+ @nter"retation

• Sinus -hythm, $eart rate F6 b"m• rontal Axis : normal

• $ori2ontal Axis : counter clockise rotation

• P- inter%al : 6#& M

• N-S com"lex : 6#64 M

• N9 inter%al : 6#) M

• +onclusion : sinus rhythm ith $- F6 b"m,


9/14

+E3 A/D +*E3 P* @Dx PDx P9x Pmo OPedu

ale75) yoAx:(Black tarry stoolsince 5 hours before

admission($istory of $e" +infection

P3:(BP: &&67F6 mm$g(P-: .6 t"m@nserted /9:

bronish-9: elena <

*ab:($emoglobin : F#66g7d*(+ : F5#.6

(+$ : ''#66 "g

$ematemesis <elena

& -u"tur3

'

Pud) astritiserrosi%e

3ndosco"y

(@nserted /9astric *a%age

)xclear luid diet x'66 cc %ia /9

(@nf# /a+l 6,HJ '6t"m(@n0# *an2o"ra2ole&x)6mg(in0# etoclo"ramid)x&6mg

(Sub0ecti%e(ital sign;BP, P-=(astric

la%age7.hours(melena


10/14


ale75) yoAx:(history of sakitkuningM 4 years ago

($istory of $ea"atitis+ @nfection ) yearsago

P3:(BP: &&67F6mm$gMsakit kunitM 4years ago

(P-: .6 t"m@nserted /9:bronish-9: elena <

*ab:($emoglobin : F#66

g7d*(+ : F5#.6 (+$ : ''#66 "g

'# +irrhosis$e"atis

'#& $e"atitis+ infection

3ndosco"y

9reat underlyingdisease

(Sub0ecti%e(ital sign;BP, P-=


11/14


ale75) yoAx:(Black tarry stooland bloody

%omiting since 5hours beforeadmission

Pe :(BP: &6676mm$g(P-: ' t"m

(+on0uncti%aanemic ;


12/14


ale75' yoAx :( *i%er diseasesince ) years agoPe:BP: &6676 mm$g

Albumin : )#66 g7dl

)#$y"oalbuminemia

)#&$y"ercatabolic state

)#' *o untake

$igh Protein diet Sub0ecti%eital sign;BP=

Pedu: 9reatment,underlyingdisease,"rognosis

+E3 A/D +*E3 P* @D PD P9 P O


13/14


ale75' yoAx :( /ausea and%omitingBP: &6676 mm$g

Ereum : .5#)6mg7dl+reatinin : &,&&mg7dl

5#A2otemia

5#& %olumede"letion

5#'$e"atorenal syndrome

-ehydration & * at 3-,continue @D /a+*6,HJ '6 d"m

A%oid ne"hrotoxicagent 3Rual uid balance

Sub0ecti%eital sign;BP=

Pedu: 9reatment,underlyingdisease,"rognosis


14/14

9hank ou

30 Maret Huzaini ckd

Documents

Transcript of 30 Maret Huzaini ckd