Professional Documents
Culture Documents
I. PATIENT’S IDENTITY
Name : Mr. A
Age : 79 years old
Sex : Male
Religion : Moslem
Job : Employee
Address : Demak
No.RM : 01-27-xxxx
Room : Baitus Salam 1
Date of examination : September 24, 2019
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• Economic Impression : enough, BPJS member
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Inspection - Static RR : 22x/min RR : 22x/min
Thoracal breathing Thoracal breathing
Hyperpigmentasi (-) Hyperpigmentasi (-)
Spider nevi (-) Spider nevi (-)
Atrofi M. Pectoralis (-) Hemithoraks D=S
Hemithoraks D=S ICS Normal
ICS Normal Diameter AP < LL
Diameter AP < LL
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PERCUSSION Upper borderline of heart : ICS II left sternal line
Waist of heart : ICS III left parasternal line
Lower right borderline of heart : SIC V linea sternalis
dextra
Lower left borderline of heart : SIC V, 2 cm medial
from linea mid clavicula sinistra
Interpretation : normal
EXAMINATION RESULTS
Inspection Simetrics
Sycatric (-)
Striae (-)
Enlargement of vena (-)
Caput medusa (-)
Spider nevi (-)
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Percussion Shifting dullness(-)
Undulation test (-)
Hepar deaf (-)
Liver span dextra 11 cm
Liver span sinistra 6 cm,
Traube’s space (-)
Costovertebral percussion (+)
Interpretation :
VII. EXTREMITIES
Superior Inferior
Interpretation : normal
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VIII. SUPORTING EXAMINATION
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Color Yellow -
Purification Agak keruh -
Protein Trace <30 (Negative) Mg/dL
Reduction >= 1000 < 15 (Negative) Mg/dL
Bilirubin 1 <1 (Negative) Mg/dL
Reaction / pH =5,0 4.8 – 7.4 -
Urobilinogen 4 <2 Mg/dL
Keton Negative <5 (Negative) Mg/dL
Nitrit Positive Negative -
Mass 1.015 1.015 – 1.025 -
Blood Negative <5 (Negative) Eri/uL
Leukocyte 15 <10 (Negative) Leu/uL
MICROSCOPIC
Epytel sel 2–4 5 – 15 /LPK
Erytrocyte 0–1 0–1 /LPB
Leucocyte 6–8 3–5 /LPB
Cillinder 0 0 – 1 (Hialin) /LPK
Paracyte Negative Negative -
Bacteri Positive 1 Negative -
Fungus Negative Negative -
Crystal Negative -
Mucous Fillament Negative -
Interpretation : Normal
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EXAM RESULT REFERENCE VALUE UNIT
HEMATOLOGY
Haemoglobin 13.9 13.2 – 17.3 g/dl
Hematocrite 37.1 33 – 45 %
Leucocyte 9.76 3.8 – 10.6 Ribu/uL
Trombocyte 205 150 - 440 Ribu/uL
Interpretation : Normal
Physical Examination
1. Overweight
2. Pain (+) upper right abdominal
3. Pain press (+)
4. Costovertebral percussion (+)
Supporting Examination
X. PROBLEM LIST
1. DM
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- DM History
- GDS 417
- Family’s history of disease
2. Nephrolithiasis
- Right Hydronephrosis G III E.C. Right Nephrolithiasis Radioopaq (Staghorn
Stone) size 5.5 x 3.5 cm
3. Overweight
- BMI : 28,28
XI. DISCUSSION
1. DM
Assessment
Glycemia Status
Complication :
- Microangiopathy : Diabetic Retinophaty, Nephropathy, Diabetic Neuropathy
- Macroangiopathy : CVD, PAD, CHD
Ip. Dx :
- HbA1c
- Funduscopy
Ip. Tx :
Non pharmacologycal
- Balanced Nutrition therapy
- Low sugar diet
- Exercise : 30 minutes a day
Pharmacologycal
- Humalog 3x1 9UI
Ip. Mx :
- Random Blood Glucose
Ip. Ex :
- Education to patient about DM
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- Do medical check up regularly
- Diet DM
2. Overweight
Assessment
- BMI : 28,28
Ip. Dx :
- BMI
Ip. Tx :
Non pharmacologycal
- Control daily calories
- Physical exercise
- Change of dietary habit
Ip Mx :
- Monitoring weight
- Waist circumference
Ip. Ex :
Education to patient about obesity
Diet high calories
3. Nephrolithiasis
Assessment
- Staghorn stone
Ip. Dx :
- RPG
Ip. Tx :
- Surgery (Consul to Urologist)
Ip Mx :
- Vital sign
- Urine Output
Ip. Ex :
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Education to patient about nephrolithiasis
Drink more water
Do medical check up regularly
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