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Report
Departement of Interna
Wednesday September 26 2018
J30
List of Patient
Identity
Name : Mrs. I
Age : 59 years old
Address : Lamongan
Admission : September 26, 2018 22:00
Anamnesis
A : Clear, gargling (-), snoring (-), speak fluently (+), potensial obstruksi (-)
B : Spontan, RR 20 x/menit, ves/ves, Rh -/-, Wh -/-, SaO2 99 % tanpa O2 support
C : Akral HKM, CRT < 2’ N 92 x TD 99/57 mmHg
D : GCS 456, lateralisasi-, PBI 3mm/3mm, RC +/+
E : temp 36.3c
– General condition : weak
– Awareness : composmentis
– GCS : 456
– H/N : a +/i-/c-/d -
lymph node enlargement at neck (-)
THORAX
– Inspection
– Symmetrical, retraction -
– Palpation
– Thrill (-), fremitus WNL
– Percussion
– Lungs: sonor / sonor
– Cor: N
– Auscultation
– Lungs: ves /ves, rh -/-, wh -/-
– Cor: S1S2 single, M -, gallop -
ABDOMEN
– Inspection
– flat
– Auscultation
– Met -, bowel sound + N
– Palpation
– Pain (-)
– Liver/Spleen within normal limit
– Percussion
– Tymphany
EXTREMITIES
– Inspection
– Clubbing fingers (-), icteric (-), cyanosis (-), edema (-),
– Palpation
– Warm, dry and pale, CRT <2’
Laboratory finding
Gula Darah Acak --> Hasil : 125 [ ] Hematokrit --> Hasil : 20.4 [ L 40 -54
SGOT --> Hasil : 59 [ 0 - 35 ] P 35 - 47 ]
SGPT --> Hasil : 29 [ 0 - 35 ] MCV --> Hasil : 93.60 [ 87.00 - 100 ]
Lekosit --> Hasil : 3.4 [ 4.0 - 11.0 ] MCH --> Hasil : 31.20 [ 28.00 - 36.00 ]
Neutropil --> Hasil : 67.7 [ 49.0 - 67.0 ] MCHC --> Hasil : 33.30 [ 31.00 - 37.00 ]
Limposit --> Hasil : 19.2 [ 25.0 - 33.0 ] RDW --> Hasil : 14 [ 10 - 16.5 ]
Monosit --> Hasil : 4.0 [ 3.0 - 7.0 ] Trombosit --> Hasil : 62 [ 150 - 450 ]
Eosinopil --> Hasil : 7.1 [ 1.0 - 2.0 ] MPV --> Hasil : 7 [ 5 - 10 ]
Basofil --> Hasil : 2.0 [ 0.0 - 1.0 ] Laju Endap Darah 1 --> Hasil : 41 [ 0 - 1 ]
Eritrosit --> Hasil : 2.18 [ 3.80 - 5.30 ] Laju Endap Darah 2 --> Hasil : 72 [ 1 - 7 ]
Hemoglobin --> Hasil : 6.8 [ P13,0 - 18,0
L14,0 -18,0 ]
Assessment
Hematemesis Melena
Anemia
Leukopenia
Thrombocytopenia
Pre Leukemia
Therapy