TEAM INCHARGE

THURSDAY, DECEMBER 9TH 2006

RESUME
NEW PATIENT
CONSULT
OUTPATIENT
REFUSED

: 15
:2
::-

KONSULTAN
1. DR.Dr. TJOK RAKA PUTRA, SpPD-KR
2. Prof. DR. Dr. W WITA, SpJP
TIM JAGA :
IA
dr. ELIZABETH
IB
dr. HERI SUTRISNO
IIA dr. IB PUTRAWAN / BUDI WIBAWA
IIB dr. BERNARD M / WANTERA
III
dr. MANGATAS SM

ID
1. AYU

SUTRISNO, F, 42
YO
TC 20.30
OBGYN

CONSULT

CONCLUSION

- AKD POST RENAL

CA CERVIX STG.
IIIB WITH ANEMIA
ON CKD C.B SUSP.
& CKD
OBSTRUCTIVE
NEPHROPATY
PLEASE
CONSULT AND
- SEVERE ANEMIA
ADVICE THERAPY
N/N ON CKD +
ACUTE BLEEDING

ADVISED
- JOIN CARE NEPHRO
- DIET 35 KAL, 1,2 GRAMS
PROT/KGBW/DAY
- IVFD NACL 0,9% 8 D/M
- PRC TRANFUSION HB
8GR%/DL
- CACO3 TAB TID
- FOLIC ACID 2 TAB BID
- TRANEXAMIC ACID 500
MG IV TID
P/
- SEARCH FOR PAST
MEDICAL RECORDS
- BT/PT/APTT & CBC POST
TRANFUSION
M/
- BLEEDING
- FLUID BALANCE

ID
2.LUH PARSI , F,
50 YO
TC:15.30
SURGERY

CONSULT
LEFT INTER
CONDILER OPEN
FRACTURE
CONSULT
EVALUATION AND
ADVICE THERAPY
FOR PREOP
DEBRIDEMENT

CONCLUSION

ADVISED

- DM
- OBS
TRANSAMINITIS CB
MUSCLE TRAUMA
DD VIRAL
HEPATITIS
-HT STG I

- JOIN CARE ENDOCRINE

- POST OP :DIET B11900
KAL, LOW SALT
- IVFD NS 12 D/M
- DRIP 8 U RI IN 500 CC
D5%
- AGREE FOR OPERATION
IF BS 200 MG/DL
P/
- RANDOM BS POST OP,
FBS 2HH PP
- LIPID PROFILE, URIC
ACID
- CONSUT TO
OPHTALMOLOGIST,
NEUROLOGY & DENTIST
- REPEAT BP
EVALUATION
M/
BS

1. RINA ASTUTI, 16 YO
KAMPIAL NUSA DUA KUTA BADUNG
CC : SWOLLEN IN ALL PART OF THE BODY
Assessment
NEPHROTIC SYNDROME

Tx
ADM DAHLIA
LOW SALT DIET
CAPTOPRIL 12,5 MG

BID
SYMVASTATIN 20 MG
OID
FUROSEMID 40 MG,
BID, 1-1-0
SPIRONOLACTON 50
MG, BID, 1-1-0

MR:01 08 61 60
TC: 10.00
Planning
HBSAG, ANTI-

HCV
USG
ABDOMEN
URINE
ESBACH (24H)

M/
BW
FLUID
BALANCE

2. MADE RENTEH, F, 66 YO
BANJAR PUSEH BATURITI TABANAN
CC: SHORTNESS OF BREATH
Assessment
COPD - SEVERE ACUTE

EXACERBATION
INFECTED
BRONCHIECTASIS

MR :01086170
TC : 10.30
Tx

ADM DAHLIA
02 2 LTR/M
IVFD NACL 0,9% +

DRIP AMINOFILIN 0,5

MG/KGBW/H
COMBIVENT
NEBULIZER @ 6H
CEFOTAXIME 1 G TID
ERITROMYCIN 500 MG
QID
BROMHEXIN C I TID
PARACETAMOL 500
MG TID (I/N)
M. PREDNISOLONE
INJ. 62,5 MG BID

Planning
GRAM

SPUTUM / ST /
CULTURE
SPIROMETRI

M/
VS
SOB
COMPLAIN

3. PUTU MAI INDRAYANI , F, 31 YO

JL. PULAU BELITUNG GG BABATAN
CC: FEVER
ASSESSMENT
DHF GRD I ( DAY 4TH )

MR:00772865
TC: 13.30
TX

ADM WK
IVFD RL 30 D/M
FREE DIET
PARACETAMOL 500

MG TID
B COMP TID
DRINK 1,5 - 2 LTR
AMOUNT OF WATER /
DAY

PLANNING
DHF

SEROLOGIC
( DAY 7th )

M/
CBC @ 24 H
VS

4. NI WAYAN SULIANTINI, F, 20 YO
JL TUKAD BANYUSARI GgXVI NO 115
CC: FEVER
Assessment
SUSP DHF GRD I

( DAY 6TH )

MR:01066184
TC:13.30

Tx
ADM BAKUNG BARAT
IVFD RL 30 D/M
FREE DIET
PARACETAMOL 500

MG TID
B COMP TAB TID
DRINK 1,5 2 LTR
AMOUNT OF
WATER/DAY

Planning
DHF

SERLOGIC
( DAY 7TH )

M/
CBC @ 12 H

5. NI NYOMAN ARTINI, F, 26 YO
BANJAR PEPET JAYA BATUBULAN
CC: SHORTNESS OF BREATH
ASSESSMENT

MR:00914766
TC: 14.30

TX

SEVERE ACUTE ASTHMA ADM

ATTACK ON MODERATE O2 4 LTR/MNT

PERSISTENT ASTHMA
G2P1001 18-19 W, S/L

IVFD NACL 0,9% +

DRIP AMINOFILIN 0,5

MG/KGBW/HH
FREE DIET
COMBIVENT
NEBULIZER @ 6 HH
M. PREDNISOLONE INJ
62,5 MG BID
BROMHEXINE C I TID

PLANNING
M/
SOB
COMPLAIN
FLUID
BALANCE

6. NI NENGAH SARI, F, 50 YO

MR:01086191
TC: 15.00

JL. LAKSMANA VII NO 125B DENPASAR

CC: FEVER
ASSESSMENT
SUSP PNA
OBS SYNCOPE C.B

ORTHOSTATIC
HIPOTENSION DD/
EPILEPSY (NEURO)

TX
ADM
JOINT CARE

PLANNING
URINE

CULTURE
/CC/ST
USG
UROLOGY

NEUROLOGY DEPT
IVFD NACL 0,9% 20
D/M
FREE DIET
CEFOTAXIME 1 GRAM
INJ TID
PARACETAMOL 500
M/
MG TAB TID
COMPLAIN OF
NEUROTROPIC VIT BID
FLANK PAIN &
FEVER

7. I NENGAH RIMA, M, 60 YO
DUSUN BAYUNG GEDE KINTAMANI
CC: SHORTNESS OF BREATH
ASSESSMENT
CKD STG V CB PNC DD:

URIC NEPHROPATY
- METABOLIC ACIDOSIS
- UREMIC
ENCEPHALOPATHY
- HYPERKALEMIA (7,52)
- SEVERE ANEMIA N/N
ON CKD
- HYPERURICEMIA
- STONE ON RIGHT
KIDNEY

MR:01086208
TC: 15.10

TX
ADM MS
02 5 LTR/M
IVFD NACL 0,9% LOADING

300CC 8 D/M
DIET 35 KAL, 0,8 GR
PROT/KGBW/DAY, LOW
PURINE
NATRIUM BICARBONATE
BOLUS 100 MEQ DRIP IN
NACL 0.9% 12 D/M
CA GLUCONATE INJ TID
GLUCOSE 50 G + INSULIN 20
IU IN 20 MNT
ALLOPURINOL 300 MG OID
FOLIC ACID 25 MG BID
CACO3 500MG TID
PRC TRANFUSION HB 8 G
%/DL (2 KOLF ON HD)
CYTO HD

PLANNING
USG

ABDOMEN
URONEFRO

M/
AGD,
ELECTROLITE,
BUN, SC POST
HD

8. NI MADE SOKA, F, 39 YO
DUSUN BAYUNG GEDE KINTAMANI
CC: DIARRHEA
ASSESSMENT
ACUTE ENTERITIS C.B

SUSP:

VIRAL INF
ENTEROPATY
DIABETIC
-HYPOKALEMIA (2.8)
-HYPONATREMIA NON
EMERGENCY (122)

DM
OBS CARDIOMEGALY

C.B SUSP
CARDIOMYOPATI DM
CKD ST I C.B SUSP DKD

MR:01086208
TC: 15.15

TX
ADM
IVFD RL 30 D/MT
DRIP RI 2U/H IN NACL 0.9%

20D/MNT TILL BS < 140

1U/H IN D5% 20D/MNT
KCL DRIP 50MEQ IN RL
2OD/MNT
CAPTOPRIL 12.5MG BID

PLANNING
CF/ANAL

SWAB
BSN/2HPP, A1C
CO EYE,
NEURO,
DENTIST DEPT
ECHOCARDIO
M/
BS @1H 6H
NA,K @6H
DIARRHEA
FLUID
BALANCE

9. NI KOMANG DARSINI, F, 37 YO
JL. WATURENGGONG GG XX /5B
CC: ABDOMINAL PAIN
ASSESSMENT

MR:01023468
TC: 18.00

TX

PLANNING

ACUTE CHOLECYSTITIS ADM CEMPAKA TIMUR USG

ABDOMEN
DM
IVFD RL 30 D/M
FASTING BS &
HYPOKALEMIA CB
CEFTRIAXONE 1 G IV

VOMITING

BID
PARACETAMOL 500
MG (I/N)
PETIDIN 25 MG IV (I/N)
RAPID INSULIN DRIP 4
IU/HH BS 110-140
MG/DL
DRIP KCL 50 MEQ IN
NACL 0,9% 20 D/M

BS 2HH PP
A1C, LIPID
PROFILE
CONSULT
OPHTALMOLOGI
ST, NEUROLOFY,
DENTIST
M/
NA K @ 6 HH
BS @ 1HH

10. I MADE MARGAWAN, M, 24 YO

BR. PUSEH BATUBULAN KANGIN GIANYAR
CC: FEVER
ASSESSMENT
SUSPECT DHF GRD I

( DAY 5TH )

TX
ADM RATNA
IVFD RL 30 D/M

MR:01086210
TC: 18.45

PLANNING
SEROLOGIC

DHF ( DAY 7TH )

FREE DIET
PARACETAMOL 500

MG TID
B COMP 1 TAB TID
DRINK 1,5-2 LTR
AMOUNT OF WATER

M/
CBC @ 12 JAM
VS

11. NI WAYAN NITI, F, 23 YO

BR. SEMAPAN CACANGSARI PETANG BADUNG
CC: FEBRIS
ASSESSMENT
OBS. BISITOPENIA C.B

SUSP DD:

APLASTIC ANEMIA
ALEUCEMIC LEUCEMIA

FEBRIS C.B SUSP ORAL

INFECTION
HEMATEMESIS MELENA

TX

MR: 01086216
TC: 18.20

PLANNING

ADM MS

BMP

IVFD NACL 0,9% 30 D/M

BLOOD

INSERT NGT TRIAL GC

REDISH GC AS PROTOCOL
FASTING
TRANEXAMIC ACID 500MG
INJ TID
OMEPRAZOLE INJ 40MG, BID
ANTACIDA SUSP C1, TID
CEFOTAXIM INJ 1 GR, TID
PARACET. 500MG, TID
TC TRANSFUSION 10BAG
PRC TRANSFUSION HB
>10

CULTUR/ST
CO DENTIST
DEPT
EGD

M/
CBC @ DAY /
POST TRANSF.
BLEEDING
VS

12. NI KOMANG SEMADI, F, 45 YO

BR. SEMAPAN CACANGSARI PETANG BADUNG
CC: SHORTNESS OF BREATH
ASSESSMENT
CKD STG V CB

SUSPECT URIC
NEPHROPATHY DD/
PNC
- NETABOLIC ACIDOSIS
- HYPERKALEMIA (6,63)
- HYPERURICEMIA
- MODERATE ANEMIA N/N
ON CKD
- HYPOALBUMINEMIA
- HT GRD I
SUSPECT PNEUMONIA

TX
ADM MS
IVFD NACL 0,9% 8 D/M
DIET 35 KAL, 0,8

PROT/KGBW/DAY, LOW SALT

DIET, LOW PURINE, LOW
KALIUM DIET
NA BICARBONATE 100 meq
BOLUS IV DRIP200 MG
MEQ IN NACL 0.9% 12 D/M
CA GLUCONAS 12MG INJ TID
GLUCOSA 50 GR +INSULIN 20
IU 20 MIN
ALLOPURINOL 300 MG OID
CAPTOPRIL 25MG BID
CACO3 TID
FOLIC ACID 25MG BID
EMERGENCY HD
CEFOTAXIME 1GR IV TID
ERYTROMYCIN 500 MG QID

MR:01086218
TC: 18.55

PLANNING
ABDOMINAL

USG
SPUTUM
GRAM/CULTURE
/ST
URINE URIC
24H

M/
BGA,BUN,CRE

A,NA,K POST
HD

13. AGUSTINUS BASUKI, M, 70 YO

JL KERTA PETASRAN VII/8
CC: SHORTNESS OF BREATH
ASSESSMENT
CAD/OMI INF-ANT-

LAT/FC IV

EDEMA PARU

OLD STROKE
BPH (POST OP.)

MR:01082273
TC: 01.30

TX
ADM ICCU
02 5L/MNT

PLANNING
CORONARY

ANGIOGRAPHY

IVFD NS 8 D/M
HEART DIET-1
FUROSEMID INJ 40MG

20 MG TID
ISDN DRIP 2MG/H
ACETOSAL 100MG
OID
CAPTOPRIL 6.25MG
TID

M/
SOB
COMPLAINT
ECG
ELECTROLITE

14. NI LUH KOMPYANG, F, 27 YO

BR. PUSEH BATUBULAN KANGIN GIANYAR
CC: FEVER
ASSESSMENT
SUSPECT DHF GRD I

( DAY 6TH )

TX
ADM RATNA
IVFD RL 30 D/M

MR:01086259
TC: 03.00

PLANNING
SEROLOGIC

DHF ( DAY 7TH )

FREE DIET
PARACETAMOL 500

MG TID
B COMP 1 TAB TID
DRINK 1,5-2 LTR
AMOUNT OF WATER

M/
CBC @ 12 JAM
VS

15. I NYOMAN SUWINDA, M, 46 YO

JL WIDA MADE PUTRA GG III/15 DPS
CC: BLOODY VOMITING
ASSESSMENT

MR: 00926695
TC: 04.45

TX

HEMATEMESIS MELENA ADM MS

C.B SUSP DD:

PEPTIC ULCER
DRUG INDUCED
(TRADITIONAL DRUG)

RHD/MSI/FC II

IVFD RL 30 D/M
INSERT NGT TRIAL GC

STOLCEL GC AS
PROTOCOL
FASTING
TRANEXAMIC ACID 500MG
INJ TID
OMEPRAZOLE INJ 40MG, BID
ANTACIDA SUSP C1, TID
CAPTOPRIL 12.5MG, BID

PLANNING
EGD
ECHOCARDIO

M/
CBC @ DAY
BLEEDING
VS

SUBJECTIVE DATA
ID

: I NENGAH RIMA, M, 60 YO

CM

: 01086208

ADD

: DSN BAYUNGGODE KINTAMANI

TC

: 15.10

CC

: SHORTNESS OF BREATH
SHORTNESS OF BREATH SINCE 2 DAYS PRIOR TO ADMISSION TO
HOSPITAL. THE PATIENT FELT VERY HEAVY & EVEN THE PATIENT CANT SLEEP
BECAUSE THIS COMPLAINT, THIS COMPLAINT HAS BEEN VERY DISTURBING. THIS
SHORTNESS OF BREATH NOT DECREASED WITH CHANGING POSITION AND
GETTING WORSED SINCE MORNING AND PATIENT SEEN DECREASED OF
CONSCIOUSNESS. THERE WASNT COUGHING, FEVER OR CHEST PAIN
COMPLAINT.
PATIENT ALSO COMPLAINED THAT HE FELT WHOLE BODY IS
WEAKENING AND FATIGUE, THIS COMPLAIN DOESNT GET BETTER EVEN AFTER
ENOUGH REST. THE PATIENT HAVE BEEN LOSING APATITE SINCE 1 MONTHS AGO
TOGETHER NAUSEA AND SOMETIMES VOMITING. THERE IS NO CHANGES IN
BOWEL HABIT.
PASSING URINE WAS COMPLAINED DECREASED SINCE 1 MONTH
WITH VOLUME ABOUT 1-2 GLASS, BUT SINCE 3 DAYS AGO ONLY ABOUT 1 GLASS.
BECAUSE SHORTNESS OF BREATH PATIENT GO TO BANGLI HOSPITAL, BUT ATTER
2 DAYS CARE DIDNT IMPROVE, PATIENT WAS REFERRED TO SANGLAH HOSPITAL

PAST MEDICAL HISTORY

THE PATIENT NEVER HOSPITALIZED BEFORE,

HISTORY OF HYPERTENSION WAS KNOWN 1 WEEK PRIOR TO
ADMISSION. HISTORY OF URINARY TRACT STONE DENIED, NO
JOINT PAIN OR DISEASE BEFORE.
FAMILY HISTORY

THERE IS NO HISTORY OF SAME DISEASE IN PATIENTS FAMILY

SOCIAL HISTORY

PATIENT WAS A FARMER, NO ALCOHOLIC HISTORY, SMOKER (+)

OBJECTIVE DATA
LOC : E2V2M3
APP : SEVERE ILLNESS
Tax : 36,6C
BW : 60 KG
HGH : 165 CM
BP : 70/PALP 120/70MMHG
PR : 78X/M
RR : 32 X/M
EYE : AN +/+ ICT-/- EDEMA (-)
ENT : DRY TONGUE (-)
NECK : JVP=PR + 0 CM H20
THORAX :
COR :
INS : ICTUS CORDIS UNSEEN
PAL : ICTUS CORDIS ICS 5 MCL
SINISTRA
PER : RB :PSL DEXTRA
LB :ICS V MCL SIN
AU : S1S2 SINGLE REGULER.
MURMUR (-)

PO:
INS : SIMETRIC STATIS AND
DYNAMIC
PAL : VF N/N
PER : SONOR/SONOR
AUS : VES +/+ RH-/-, WH -/ABD
INS
AUS
PAL

:
: DISTENDED (-)
: BS (+/N)
: SUPPLE, L/S NOT PALP
BALOT. (-)
PER : TYMPHANI (+)
EXTREMITY :
WARM +/+ EDEMA -/-

LABORATORY
CBC :
WBC: 7,81
HGB : 5,97
MCV : 96,7
MCH : 31,7
HCT : 18,1
PLT : 239

BC
:
GLU : 108
BUN : 240 208
SC : 27,1 24.6
AST : 29
ALT : 16
TP : 64
ALB : 3,2
URIC : 14,0
CHOL : 242
TG : 418
GLOB : 3,2
CCT : 2,46

LABORATORY
BGA :
PH
: 7.1
PCO2 : 5.7
PO2 : 155.1
NA
: 142
K
: 7.52
HCO3 : 1.8
BE
: -27,7
S02 : 98.4%

7.39
9
191
151
4.0
5.4
-19.6
100%

7.31
5.0
149.2
148
4.7
2.5
-23.8
98.8%

ECG
SINUS RHYTHM 81X/MNT, RIGHT AXIS
T-TALL (+)
CHEST X-RAY
CTR 50,9%, TAIL(+)
INFILTRATE (-)
CPA SHARP D/S
BOF
OPAQUE STONE ON RIGHT KIDNEY

DIAGNOSIS
CKD
AKI
HIPERKALEMI
ENCEPALOPATHY UREMICUM
ANEMIA
HIPERKOLESTEROLEMIA
NEFROLITIASIS
HEARTF FAILURE
ASIDOSIS METABOLIK

DIAGNOSIS
CKD
AX: sesak,

ASSESSMENT
CKD STG V CB PNC DD:URIC NEPHROPATY

METABOLIC ACIDOSIS
UREMIC ENCEPHALOPATHY
HYPERKALEMIA (7,52)
SEVERE ANEMIA N/N ON CKD
HYPERURICEMIA
STONE ON RIGHT KIDNEY

DYSLIPIDEMIA

THERAPY
ADM MS
02 5 LTR/M
IVFD NACL 0,9% LOADING 200CC 8 D/M
DIET 35 KAL, 0,8 GR PROT/KGBW/DAY, LOW PURINE
NATRIUM BICARBONATE BOLUS 100 MEQ DRIP IN NACL 0.9%

12 D/M
CA GLUCONASE INJ TID
GLUCOSE 50 G + INSULIN 20 IU IN 20 MNT
ALLOPURINOL 300 MG OID
FOLIC ACID 25 MG BID
CACO3 500MG TID
SYMVASTATIN 20MG OID
PRC TRANFUSION HB > 8 G%/DL (2 BAG ON HD)
CYTO HD

PLANNING
P/
USG ABDOMEN/UROLOGY
URONEFRO DISCUSSION
LIPID PROFILE

M/
AGD, ELECTROLITE, BUN, SC POST HD
VS, SOB