Scribd Logo
Upload

Welcome to Scribd!

  • 21 views

    MR Sip

    Uploaded by

    Felicia adeline Christian
    The patient is a 59-year-old Hindu woman who presented with shortness of breath for 1 month and weakness for 2 months. On examination, she had edema in her lower extremities and decreased breath sounds on the right lung. Laboratory tests found anemia, elevated blood glucose and kidney function, and a pleural effusion on the right side. She was diagnosed with type 2 diabetes mellitus, hypertension, suspected ureteral stones, suspected congestive heart failure, and suspected pleural effusion.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    MR Sip

    Uploaded by

    Felicia adeline Christian
    21 views26 pages
    The patient is a 59-year-old Hindu woman who presented with shortness of breath for 1 month and weakness for 2 months. On examination, she had edema in her lower extremities and decreased breath sounds on the right lung. Laboratory tests found anemia, elevated blood glucose and kidney function, and a pleural effusion on the right side. She was diagnosed with type 2 diabetes mellitus, hypertension, suspected ureteral stones, suspected congestive heart failure, and suspected pleural effusion.

    Original Description:

    sip

    Original Title

    MR SIP

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The patient is a 59-year-old Hindu woman who presented with shortness of breath for 1 month and weakness for 2 months. On examination, she had edema in her lower extremities and decreased breath sounds on the right lung. Laboratory tests found anemia, elevated blood glucose and kidney function, and a pleural effusion on the right side. She was diagnosed with type 2 diabetes mellitus, hypertension, suspected ureteral stones, suspected congestive heart failure, and suspected pleural effusion.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    21 views26 pages

    MR Sip

    Uploaded by

    Felicia adeline Christian
    The patient is a 59-year-old Hindu woman who presented with shortness of breath for 1 month and weakness for 2 months. On examination, she had edema in her lower extremities and decreased breath sounds on the right lung. Laboratory tests found anemia, elevated blood glucose and kidney function, and a pleural effusion on the right side. She was diagnosed with type 2 diabetes mellitus, hypertension, suspected ureteral stones, suspected congestive heart failure, and suspected pleural effusion.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    You are on page 1of 26

    July 9th , 2012

     Name : NWS
     Sex : Female
     Age : 59 yo
     Religion : Hindu
     Status : married
     Adress : Singaraja
     RM : 01514111
     ToA : 15.30
     CHIEF COMPLAIN  breathlessness

    Patient came with chief complain breatlessness


    since 1 month BATH and worsen on yesterday night.
    It worsen when she in supine position, and get
    better in sitting or standing. Night sweating, cough,
    and fever was denied.

    She also complained of weakness in her body since 2


    month. It made patient couldn’t do her daily
    activity.
     She also complain of pain when urinating
    since 1 week and the frequency was increase
    in the night. Blood in urine was denied by the
    patient.
     History of blurred vision and numbness on
    foot was denied.
     She had history of DM since 4 year with BS 320, but she
    didn’t get any medication. She also had hypertension and
    renal stone, she get any drug but she didn’t remember the of
    the drug..

     Family history
    No one in the family has the same complain like her. There is
    no history of DM, hypertension, and heart disease in her
    family
     Social history
    History of smoking and alcohol was denied.
    Appearance : moderately ill
    GCS : E4V5M6
    BP : 150/90 mmHg
    PR : 85 times/minutes
    RR : 22 times/minutes
    Axillary Temperature : 37.5° celcius
    VAS : 0/10
    Weight : 50 kg
    Heigth : 158 cm
    BMI : 20 kg/m2
    Eyes : anemia -/-, icterus -/-, RP +/+ isochoric,
    palpebral oedema -/-
    ENT : tonsil T1/T1; pharing hiperemis (-)
    Neck : enlargement of lymph node (-)
    JVP  PR ± 0 cmH2O
    Chest (Thorax) :
    Cor: Inspection: ictus cordis unseen
    Palpation: ictus cordis unpalpable
    Percussion: UB ICS 2 MCL S, LB ICS 5 (2 cm lateral
    to MCL S), RB PSL D
    Auscultation: S1S2 single, regular, murmur (-)
    Po : Inspection: simmetrical static, assimetric dinamic
    Palpation: vocal fremitus N N
    N N
    decrease N
    Percussion: sonor sonor
    sonor sonor
    dullness sonor

    Auscul: vesicular Rhoncy Wheezing


    + + - - - -
    + + - - - -
    + + - - - -
    Abdomen : Inspection : distention (-)
    Auscultation: Bowel sound (+) normal
    Palpation: Tenderness (-), Liver/spleen unpalpable,
    Percussion: Tymphani

    Extremity : edema - - , warm + +


    + + + +
    Parameter Result Unit Remarks Reference range
    WBC 9,60 103/μL 4,5 – 11,00
    -Ne 6,50 (67%) 103/μL 2,50 – 7,50
    -Ly 2,10 (22,2%) 103/μL 1,0 0– 4,00
    -Mo 0,6 (6,3%) 103/μL 0,10 – 1,20
    -Eo 0,3 (3,4%) 103/μL 0,00 – 0,50
    -Ba 0,10 (0,6%) 103/μL 0,0 0 – 0,10
    RBC 4,80 106/μL 4,00 – 5,20
    HGB 14,30 g/dL 12,00 – 16,00
    HCT 42,10 % 41,00 – 55,00
    MCV 87,60 fL 80,00 – 100,00
    MCH 87,60 pg 26,00 – 34,00
    MCHC 29,70 g/dL 31,00 – 36,00
    RDW 15,70 % H 11,60 – 14,90
    PLT 248,00 103/μL 150,0 – 440,0
    MPV 8,60 fL 6,80 – 10,00
    Parameter Result Unit Remarks Reference range
    pH 7,42 - 7,35 – 7,45
    pCO2 37 mmHg 35,00 – 45,00
    pO2 62 mmHg L 80,00 – 100,00
    HCO3- 24 mmol/L 22,00 – 26,00
    TCO2 mmol/L 24,00 – 30,00

    BE(B) -0,5 mmol/L -2 – 2


    SO2c 92 % --
    Natrium 130 mmol/L 135,00 – 145,00
    Kalium 3,8 mmol/L 3,40 – 4,80
    Parameter Result Unit Remarks Reference range
    SGOT 29,80 U/L 11,00 – 33,00
    SGPT 34,20 U/L 11,00 – 50,00
    BUN 14 mg/dL 8,00 – 23,00
    Creatinine 0,62 mg/dL 0,50 – 1,20
    Random blood 409 mg/dL H 70,00 – 140,00
    glucose
    LDH 528,10 U/L H 110 - 210
    Protein total 6,073 g/dL 6,00 – 8,00
    Asam urat 2,70 g/dL 2,00-7,00
    parameter result
    Tes rivalta +
    makroskopis
    - warna Kuning jernih
    -bekuan negatif
    -darah negatif
    Mikroskopis
    -eritrosit 15 – 20
    -bentuk Utuh & dismorfik
    Cell 471/mm3
    mono 80%
    poly 20%
    parameter result unit remark reference range
    Protein total 1,67 g/dl L 6,4 – 8,3
    LDH 132 U/L L 240 - 480
    Glucose 367 mg/dL H 50 - 75

    Protein pleural fluid/protein serum : 1,67/6,073 = 0,23


    LDH pleural fluid/LDH serum : 132/528 = 0,25
    “TRANSUDAT”
    Parameter Result Unit Remarks Reference range
    pH 6,00 - 5-8

    Leucocyte 500,00 Leu/ +3 Negative

    Nitrite - - Negative

    Protein - Mg/dL +1 Negative

    Glucose 1000 Mg/dL +4 Normal

    Ketone - Mg/dL Neative

    Urobilinogen norm Mg/dL 1 mg/dL

    Bilirubin - Mg/dL Negative

    Erytrocyte 150,00 Ery/ +4 Negative

    Specific gravity 1,015 1,005-1,020

    Color yellow p.yellow-yellow

    Sedimen Urine:
    -Leucocyte 10-13 /lp <6/lp
    -Erytrocyte 4-6 /lp <3/lp
    -Sel Epitel - -
    -Sel Gepeng 3-5 /lp -
    -Lain-lain Bacteri + /lp -
    /lp -
    /lp -
     Cor : 67%
     Pulmo: Opacity in right
    lower lobus
     Costophrenic angle :
    right blunted left sharp
     Bones: no abnormality
    seen

     Conclusion:
    pleural effusion D
    cardiomegaly
     Radioopaque in L4-5
     Conclusion :
    susp. Ureteral stone
    (D_
     Sinus rythm
     Axis normal
     HR 100 x/menit
     P wave normal
     PR interval
    normal
     QRS normal
     ST-T change (-)
     Conc. : Normal
    sinus rhytm
    DM Type 2
    HT gr 1
    Susp. Ureteral stone D + susp.ISK
    Susp. CHF
    MRS
    IVFD NaCl 0,9% 20 dpm
    O2 4 lpm
    Captopril 2 x 25 mg
    Ciprofloxacin 2 x 200 mg
    Insulin
     USG abdomen
     Echocardiografi
     Opthalmologist (funduskopi)
     FBG, PPBG, HbA1C, lipid profile

     Vital Sign, complaint


     BS
    THANK YOU
    Prinsip : gangguan keseimbangan protein dan
    cairan di dalam rongga pleura

    1. EKSUDAT
    infeksi / inflamasi  meningkatkan permeabilitas kapiler
    pemb darah

    2. TRANSUDAT
    pada CHF, sirosis hati, sindrom nefrotik
    effusion occurs because the increased amounts of fluid in
    the lung interstitial spaces exit in part across the visceral
    pleura. This overwhelms the capacity of the lymphatics in
    the parietal pleura to remove fluid.
    Light kriteria : (analisis pleural fluid)

    1. Protein pleural fluid/ protein serum > 0,5 =


    eksudat, jika < 0,5 = transudat
    2. LDH pleural fluid/ LDH serum > 0,6 =
    eksudat
    3. LDH pleural fluid > 2/3 upper limit normal

    Tes Rivalta  +  eksudat


    Kidney disease  3 month :

    GFR (Cockroft Gault)

    < 60 ml/mnt/1.73 m2  60 ml/mnt/1.73 m2


    - CKD

    Kidney damage (-) Kidney damage (+)


    - normal (single kidney, imaging,
    Komposisi darah/urin)
    - CKD
    Framingham criteria : (1 mayor + 2 minor)
    Mayor :
     Paroksismal noktural dispnea
     Distensi vena leher
     Ronki paru
     Kardiomegali
     Edema paru akut
     Gallop s3
     Peningkatan JVP
     Reflux hepatojugular
    Minor :
     Edema ekstrimitas
     Batuk malam hari
     Dispnea d’effort
     Hepatomegali
     Efusi pleura
     Penurunan kapasitas vital 1/3 dari normal
     takikardia

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy