Duty Report

Saturday, June 10th 2017

dr. Ricky
Physician in charge:
I : dr. Adys, dr. Toni, dr. Ricky
II CVCU : dr. Norma
II HCU : dr. Edy
II UGD : dr. Rahmad, dr. Yuni
Chief : dr. Ramadhan
Consulan: dr. Syifa Mustika, SpPD

Summary of Database:
Mrs. S / 39yo / w.28
Anamnesis: autoanamnesis
Chief complaint: Shortness of breath
Patient suffered from shortness of breath since 1 week ago. The shortness of breath felt it especially when she doing
heavy activity, it didnt relieve by took a rest. she need more pillow to reduce her shortness of breath. Sometimes she
woke up in the middle of the night because of shortness breath.
Patient suffered from chronic cough since 1 week ago. She complained chronic cough with whtish sputum. There is no
fever now.
She complained about epigastric pain since 1 day ago. She didnt feel nausea and vomitting.
She already diagnosed Chronic kidney disease since 1 year ago at RSSA. She had already performed hemodialized at RSSA
hospital every Tuesday. She suffered from hypertension since 2 years ago and didnt routinely control. The highest blood
pressure she got was aobut 180/--. She didnt suffer from diabetes mellitus.

History of past illness:

There is no past illness history.
History of family:
No family that have same complain with her. No family member that having diabetes, hypertension, nor chronic kidney
disease
History of medicine:
After she got haemodyalized, she routinely took valsartan 1x80 mg and amlodipine 1x10 mg
History of took extra joss (+) since 5 years ago 3 times a week
History of privation and social:
She is married. She had 3 children. She worked as a housewife

Physical Examinations
General appearance looked moderately ill GCS 456
Ward BP = 170/120 mmHg PR = 98 bpm regular RR = 22 tpm Tax : 36.7 C
IGD : 270/ 158 mmHg

Head Pale conjunctiva (+) Icteric sclera (-)

Visus : OD LP (+), OS LP (+)
Neck JVP R +2cmH2O 30 degree, lymphnode enlargement (-)
Chest
Heart: Ictus invisble and palpable at ICS VI 1 cm lateral MCL S
LHM ictus RHM: PSL D
S1, S2 single, murmur (-) gallop (-)
Lung: Symmetric, SF D=S,
Percusion: S S V V Rh - - Wh - -
S S V V -- - -
 S S V V ++ - -
Abdomen soefl, bowel sound (+) normal,
liver span 8cm, traubes space tympani, shifting dullness (-)
Extremities edema -/-
-/-
Laboratory Findings
LAB VALUE NORMAL LAB VALUE NORMAL
Hemoglobin 6.2 11,0-16,5 g/dl RBS 105 < 200 mg/dl
MCV 85.90 80-96 fl Ureum 133.60 10-50 mg/dL
MCH 28.30 26,5-33,5 pg
Leukocyte 12980 3.500-10.000/L Creatinine 15.58 0,7-1,5 mg/dL
Eo/Bas/Neu/Li 1.2/0.3/83.2/1 0-4/0-1/51-67/25- BUN/Cr 6.46
mf/Mon 7.2/.31% 33/2-5
PCV 18.70 35-50% eGFR 3.56
Trombocyte 238.000 150.000- Ca 9.4 8.6-10.3 mg/dl
390.000/L
P 4.9 2.5-4.5 mg/dl
Natrium 138 135-153 mEq/L
Kalium 4.41 3.5-5.1 mEq/L
Chlorida 114 98-109 mEq/L

URINALISA
LAB VALUE LAB VALUE

Urinalysis Cloudy 10 x

Epithelia 0
6.0 .
PH 2

SG 1.015 Cylinder -

Glucose - Hyaline -

Protein 3+ Granular -

Keton Negatif Leukocyte -

Bilirubin Negatif Erythrocyte -

Urobilinogen Negatif 40 x

Nitrite
Erythrocyte 2603.7
Positive Eumorfik 98 %
Dismorfik 2%

Leucocyte 1+ Leukocyte 164.3

Erythrocyte 1+ Crystal -

Bacteria 85.9 X 103

 Fungal -

CXR (9/6/2017)
1. edema pulmonum
2. efusi pleura bilateral

EKG ( 9/6/2017)
Sinus Tachychardia with 108 bpm

CUE AND CLUE PL IDx PDx PTx PMo and

PEdu
Female/46 yo 1. Shortness of 1.1 uremic lung NT pro BNP Bed rest semifowler Subjective
Ax breath 1.2 HF Stage C Fc Echocardiog postion Vital sign
Shortness of breath IV raphy O2 2-4 lpm via nc Rhonki
Dyspnoe deffort 1.3 HT emergency Negative fluid Urine
Paroxysmal Nocturnal balance -500 cc/24 production
dyspnoe hours Fluid balance
Diagnosed CKD since 1 year Drip furosemide 10
ago mg / jam
Already performed Drip GTN 5-200 mcg /
hemodialized every Tuesday kgbb until 25 % MAP

PE PO :
TD 274/ 158 mmHg (IGD) --- Valsartan 1x160 mg
> 170/120 (ward) Amlodipine 1x10 mg
N 98x/menit CaCO3 3X500 mg
RR 22x/menit
Tax 36.7 derajat
Saturasi O2 99 % on NC
Ictus invible and palpable
ICS VI 1 cm lateral MCL S
LHM ictus, RHM PSL D
Rhonki at basal lung D/S

Lab
ur/cr 133.60/15.58 BUN/Cr
6.46 eGfr 4.08
P 4.9
HB 6.2

CXR :
Edema pulmonum
Efusi pleura bilateral

Female/46 yo 2. CKD st 5 On 2.1 HTN Bed rest semifowler Subjective

Ax Routine HD postion Vital sign
Diagnosed CKD since 1 year O2 2-4 lpm via nrbm Urine
ago Negative fluid production
Already performed balance -500 cc/24 Fluid balance
hemodialized every Tuesday hours Ureum
Ht + Drip furosemide 10 Creatinine
Routinely took extra joss mg / jam electrolite
Drip GTN 5-200 mcg /
PE kgbb until 25 % MAP
TD 274/ 158 mmHg (IGD) --- PO :
> 170/120 (ward) Valsartan 1x160 mg
N 98x/menit Amlodipine 1x10 mg
RR 22x/menit CaCO3 3X500 mg
Tax 36.7 derajat
Saturasi O2 99 % on NC HD elektif
Ictus invible and palpable Blood tranfusion
ICS VI 1 cm lateral MCL S durante HD
LHM ictus, RHM PSL D
Rhonki at basal lung D/S

Lab
ur/cr 133.60/15.58 BUN/Cr
6.46 eGfr 4.08
P 4.9
HB 6.2

CXR :
Edema pulmonum
Efusi pleura bilateral
Female / 46 yo 3. anemia 3.1 chronic disease SI, TIBC, Fe Transfusion PRC 1 Subjective
normochrome pack durante HD Vital sign
Diagnosed CKD since 1 year normocyter 3.2 defisiensi EPO CBC
ago Plan for giving epo
Con6.2ungtiva anemic 3.3 Fe deficiency
Hb 7
mcv/mch 85.90/28.30

Female / 46 yo 4. Hypertension 4.1 primary funduscopy Drip GTN 5-200 mcg / Blood
Ax emergency 4.2 secondary kgbb until 25 % MAP Pressure
SOB
Diagnosed hypertension PO :
since 2 years ago Amlodipine 1x10 mg
CaCO3 3X500 mg
TD 274/ 158 mmHg (IGD) --->
170/120 (ward)

Female / 46 yo 5. HF stage C Fc 5.1 HHD NT pro BNP Bed rest semi fowler Fluid balance
IV 5.2 Uremic Echocardigr position
Dyspnoe d effort cardiomiopathy aphy Fluid balance -500 cc
PND / 24 hour
SOB Drip furosemide 10
mg / hour
PE :
Ictus invible palpable at ICS
VI 1 cm lateral MCLS

CXR :
Edema pulmonum

Female / 46 yo 6. HAP Sputum IV levofloxacin 1x500 CBC

Chronic cough culture + mg continue with iv Urinalysis
sensitivity levofloxacin 1x500
Lab: test mg every 48 hour
Leucosyte 12980
1.2/0.3/83.2/17.2/.31% PO nac 3x200 mg