Duty Report MARCH 22ND 2017: Anemia On CKD
Duty Report MARCH 22ND 2017: Anemia On CKD
Duty Report MARCH 22ND 2017: Anemia On CKD
DOCTERS ON DUTY:
COASS ON DUTY: SARAH JIHAAN AND GESTI CHAERUNNISA
FACULTY OF MEDICINE UPN VETERAN JAKARTA
DEPARTEMENR OF INTERNAL MEDICINE INDONESIA ARMY
CENTRAL HOSPITAL GATOT SUBROTO
PATIENT RECAPITULATION
Mrs Fitri Widyaningsih 40th mieloma
multiple + hipokalsemia +
Hipoalbuminemia
Mrs Among 62nd anemia on CKD
Mr Rahmat Anemia aplastik
PATIENTS IDENTITIY
NAME : Mrs Among
SEX : Female
AGE : 62 nd yo
OCCUPATION : IRT
ADDRESS : St Kalibaru Jakarta Utara
DATE OF ADMISSION: Wednesday 22 nd
2017
ANAMNESIS
Autoanamnesis on March 22 nd 2017
CHIEF COMPLAINT
General weekness since 1 days ago
HISTORY OF PRESENT
ILLNESS
Patients was admitted with general weekness all of his body since
1 months. At first, patient can do the daily activities by herself. Her
complain become worsen since 1 day ago till she could not
continue her activities. She also complained of having nausea and
vomit with water and food one time. It comes reappear. She
denied chest pain
Patient also complain low back pain that move to her stomach.
Scala of pain is 6.
There were no complain of micturition and defecation the quantity
are within normal limit. Fluid balance of input and output was
equal.
The mass is on the roof of the mouth. Patient loses her weight so
quickyl during 1 month, from 65 kg to 50 kg.
Patient has been hospitalized RS Koja 1 month ago with the same
clinical manifestations.
PAST ILLNESS HISTORY
Uncontrolled hypertention since 1 year
ago
Cardiac disease (-)
Diabetes (-)
FAMILY ILLNESS HISTORY
No famo;y member with the same
symtpom
Hypertension, diabetes, cardiac illness,
allergy (-)
PHYSICAL EXAMINATION
General Examination
General condition:good
Vital sign
Cardiac examination
- Inspection: ictus cordis not visible
- Palpation: ictus cordis not palpable
- Percussion: right cardiac border at ICS IV right parasternal line,
left cardiac border at ICS V left midclavicular line, upper border
at ICS III left parasternal line
- Auscultation: normal S!/S2 regular, no murmur, no gallop
Abdomen
- Inspection: flat, no skin lession/scar
- Auscultation: bowel sound (+) 3 times per minute
Percussion: tympani on four abdominal quadrant,
Anemia
Base on
Anamnesis: general weekness,headache
Physical examination: conjungtiva anemis +/+
Lab examination: Hb: 6, Ht 17, eritrosit 1,7, MCV MCH MCHC
normal
Assesment: transfusi PRC 900 cc
CKD
Anamnesis: Past hyptention, weak, nausea and vomit
Physcal examination: Hb 6, ht 17, ureum169 kreatinin 9,1
Assesment: check AGD, USG abdomen, rontgen thorax,
hemodalisis
Renal colic
Anamnesis: low back pain move to stomach 1 week ago
Physical examination: CVA (+)
Assesment: abdomen rontgen
Monitoring: Pain scale
Prognosis
Quo ad Vitam : Dubia ad bonam
Quo ad Functionam : Dubia ad bonam
Quo ad Sanationam : Dubia ad bonam