case dr arief
TRANSCRIPT
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Chronic Kidney Disease e.c Nephrotic
Syndrome
By:DINI NOVIANI PRATIWIO3008084
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ANAMNESE
Autoanamnese on 28th
of June2012 at 13.00
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Mrs. EncumName
51 years oldAge
femaleSex
Jogol 04- KarawangAddress
Elementary schoolEducation
HousewifeOccupation
IslamReligion
MarriedMarital status
June 26 th 2012Admitted
JatisariTaken from
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HISTORY TAKING
CHIEFCOMPLAINT
Swelling of face, abdomen
and legs since 3 month
ADDITIONALCOMPLAINT
Pain on the waist
Slightly short of breath
Headache
Pain on urinationNause
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HISTORY OF PRESENT ILLNESS
A patient came to Emergency Unit RSUD Karawang with a complaint of
swelling of face, abdomen and legs since 3 month before admission. The
symptom appeared first on the face then goes to the stomach and legs. The
swelling of the eyelid begins especially in the morning. When the swelling get
worsen, shes having slight short of breath. This shortness of breath is notaffected by cold, dust, or emotion, and no wheezing. She denied of having a
fever, no vomitting but suffered a bit of headache which occur once at times
and nausea
She also complained of having pain on her waist three month beforeshe was admitted and feeling pain during urination, the colour of the urine is
dark yellow with slightly dusk and foamy but the frequency is not decreased and
have no blood appearance. Defecation is normal. She also complained she had
lost weight since one year ago from 75 kg to 60 kg.
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Picture
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HISTORY OF PAST ILLNESS
HYPERTENSION
( + )
DIABETES
( - )
KIDNEY DISEASE
( - )
ASTHMA
( - )
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FAMILY HISTORY
No one in herfamily got
disease likehers
Diabetesmellitus -
Hypertension-
Asthma -
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MEDICATION HISTORY
The patient has never beenadmitted to hospital before
Not to consume certain drugs only
taking panadol just to get rid of the
headache
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PERSONAL AND SOCIAL HISTORY
Noconsumptionof herbal
drink
No smoke,no
consumptionof alcohol or
drugs
Seldomexercise
http://www.google.co.id/imgres?imgurl=http://rumahkaca.info/wp-content/uploads/8169c__olahraga-untuk-pengobatan-diabetes.jpg&imgrefurl=http://rumahkaca.info/7-tips-agar-tetap-termotivasi-berolahraga/&usg=__zS5UG1O-DgJ2ZhyvURySBrXw4EY=&h=380&w=379&sz=29&hl=id&start=18&zoom=1&tbnid=NWqE4sa7oh_ULM:&tbnh=123&tbnw=123&ei=GyB0T5DKBY_zrQf1stHCDQ&prev=/search?q=TIDAK+BEROLAHRAGA&um=1&hl=id&biw=1024&bih=372&noj=1&tbm=isch&um=1&itbs=1 -
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General condition
General appearance moderately ill
conciousness
Compos mentis
Height
165 cm
Weight
60 kg
BMI NORMAL
22,2kg/m2
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VITAL SIGN
BLOODPRESSURE
: 180/100
TEMP : 36,8C
HEART
RATE :64x/mn
RESP RATE: 20x/mn
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PHYSICAL EXAMINATION
NORMOCEPHALY
HEAD
ANEMIC CONJUCTIVA +/+
ICTERIC SCLERA -/-
PERIORBITAL ODEMA +/+
EYES
LYMPYH NODE IS NOT PALPABLE THYROID GLAND IS NOT PALPABLE
JVP 5+2 cmH2O
NECK
Lip cyanosis(-) pallor (-)
Pharynx hyperemic (-), symmetrical, uvula midline
MOUTH
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THORAX
INSPECTION
Ictus Cordis is visible
ICS LMCSPALPATION
Ictus cordis is palpable at 5th ICS LMCS
PERCUTION
Right heart border: ICS III-V LSD
Left heart border: ICS V 1cm medial LMCS
Upper heart border: ICS III LPSS
AUSCULTATION
Regular I II Heart Sound,
Murmur (-), Gallop (-)
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Lung Examination
THORAX
Inspection :Symmetrical
Supraclavicula retraction(-)
Intercostalis retraction(-) Palpation :Equal vocal fremitus
Percussion :Sonor in both lung
Auscultation :Vesicular breath sound in both lung
Wh -/-, Rh -/-
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Abdominal Examination
InspectionBrown skin, distended abdomen
Palpation
No Pain on palpation at Epigastric Liver not palpableSpleen not palpable
PercussionNo pain present on abdominal percussion
Sound DullnessShifting dullness (+)CVA (-)
AuscultationBowel sound (+) 2 times/minute. Arterial bruit (-), venous hum
(-)
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Extremity ExaminationExtremity examination
WARM ACRALS
OEDEM
+ +
+ +
- -
+ +
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Laboratory findings
Test Result Normal values
Hb 7,1 (12 17) g%
HT 28 (37 48) %
Trombocyte 104.000 (150.000 450.000) /ul
Leukocyte 4100 (5000 10000) /ul
Blood sugar 140 70 140 mg/dl
Ureum 68,7 10 45 mg %
Creatinin 1,60 0,4 1,5 mg%
Total Protein 4,57 6.1- 8,2 gr&
Albumin 1,91 3,5 5,0 mg%
Globulin 2,4 2,6 3,6 mg%
Blood :29th June 2012
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Laboratory findings
TESTS RESULT NORMAL
Colour and
turbidity
Yellow, turbid
pH 6,5 4,5-8,0
Protein + 2 -
Epitel +1 1
Leukosyte 3-5/LPB 0 5 / LPB
Eritrosit 1-2/LPB 0 5 / LPB
Urinalysis :
29th June 2012
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Laboratory findings
Test Result Normal
Cholesterol 210
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Resume
HistoryTakingSwelling of
face, abdomen& legs 3 monthbeforehospitalized.
Slight short ofbreath.
Headache.
Pain onurination.
Pain on waist.Nausea Ph
ysicalExa
mination
Periorbitaloedema +/+
Anemicconjungtiva +/+
Shifting dullness(+)
oedema of legs+/+.
AdjuvantTest
Hb : 7,1 g %.
Ht : 28 %.
Albumin : 1,91 mg
%.Globulin : 2,4 mg %
Cholesterol : 210mg/dl
Ureum: 68,7 mg%
Creatinin :1,60 mg%GFR : 39,4
Urinalysis : turbid,protein +2
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MALNUTRITION
ACUTEGLOMERULONEPHRITIS
CONGESTIVE HEARTFAILURE
DIFFERENTIAL DIAGNOSIS
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WORKING DIAGNOSIS
3rd grade of Chronic
Kidney Disease e.c
Nephrotic Syndrome
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RenalBoipsy
ECG
RontgenThorax
SUGGESTED
EXAMINATION
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THERAPY
Consumption of 0.8
grams protein / kg / day
Diets low in SALT
bed rest
IVFD D 5% 8 dpm.
Transfusi PRC 3 kolf
Lasix 2 x 1amp.
Caco3, as folat 3x1 tab
Methylprednisolon
3x62,5mg.
Ranitidin 2 x 1 amp.
Symvastatine 1x 10mg.
Captopril 3 x 6,25 mg.
Albumin 20% 1x1.
Ketorolac 3x1 amp
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prognosis
Adsanationam
dubia admalam
AdFungsionam
dubia ad
malam
Ad Vitam
Dubia adbonam
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