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Social History:
Review of System:
Fever was denied
Physical Examination
General appearance looked moderately ill Sat O2 98% on room air
GCS 456 VAS 0/10
BP 160/90 mmHg PR 90 bpm regular strong RR 20 tpmregular Tax 37,1 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+ 3cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-
Objective
BP 160/90
Anemic conjungtiva +)
Extremenities edema D/S
Laboratory
Hb 4.8/ Saturasi transferrin
29%
Ur/Cr 130.3/11
K 5.35
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs Siti Wahyuni/ 48 yo/ 2. Anemia 2.1 Deficienci • Transfusi PRC 2 labu Vital sign
Ward 25 Bed 1.6 renal EPO durante HD
Subjective 2.2 Anemic
- Decrease of conjungtiva
RBC life span
Objective
Anemic conjungtiva +)
Laboratory
Hb 4.8/ Saturasi transferrin
29%
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs Siti Wahyuni/ 48 yo/ 3. Hipertensi 3.1 Secondary Funduscopy - Amlodipin 1X10 mg Vital sign
Ward 25 Bed 1.6 on treatment 3.2 Primary especially
BP
Subjective
Subjective
- Abdominal pain since 5
days before admitted
- Nausea and vomiting,
also happened 2 years ago
- diagnosed with CKD
since 2 years ago
- Patient had routinely
hemodialized twice a week
Objective
BP 160/90
Laboratory
-