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Harki, 15 y.

o, MW 06
cc : Patient want to put in CAPD Present Illness History :  Patient want to put in CAPD  Patient was hospitalized at RSUP M.Djamil with diagnose CKD and have hemodialisa 12 times. Patient have known attached CVP-HD since 2 months ago.  Breathlesness (-)  Nausea and vomitus (-)  Coughing (-)  Mixturation (+) normal  Defecation (+) normal

rales -/-. wheezing -/- . Consc : CMC. anemis -/Lung : • Inspection : simetris. T : 36. static and dinamic • Palpation : stem fremitus right = left • Percution : sonor • Auscultation : vesiculer.Physical Examination : GA : Moderate. BP : 110/70 HR : 84x/I. RR : 21x/I.8 C Eyes : Icterus -/-.

bowel sound (+) normal. Extremitas : Oedem -/- . reguler rhtym. bruit (-) Abdomen : Enlargement of abdomen (-). liver and spleen not palpable.Cor : ictus palpable 2 fingers medial LMCS RIC IV.

2 gr/dl Ht : 31 % Leukosit : 22.000 /mm3 Na : 136 mmol/L K : 3.6 mg/dl .Lab : Hb : 10.6 mmol/L Cl : 101 mmol/L Ureum : 34 mg/dl Creatinin : 3.800 /mm3 Trombosit : 272.

c GNC on HD routine attached CVP-HD • Susp urinary tract infection Th/  Rest/ low protein 28 gr  Bicnat 3 x 500 mg  As. Folat 1 x 5 mg  Ceftriaxone 1 x 2 gr  Fluid Balance .WD/ • Chronic kidney disease stg V e.

Planning : • Consult surgery .