DUTY Report

February 14th , 2018

 Ismael, 64 yo, male, HCU

 Cc:
 Breathlessness increased since 3 days ago.

 Present Illness History

 Breathlessness increased since 3 days ago, affected by activities,
not fluting.
 History of waking in the night because of short breath (+), history
of swollen legs (+)
 Patient used to sleep with more than 2 pillows.
 Fever since 3 days ago, fever was high, no sweating
 Coughing since 2 days ago, sputum (+)
 Epigastric pain (+), nausea (+), vomit (-)
 Tea-coloured urine (-)
 Black stool (-)
 History of hypertension (+), control irregularly
 History of diabetes (+), control irregularly
Past Illness History

 History of hypertension (+)

 Histrory of DM (+)
Physical Examination

 Consciousness level: CMC

 BP : 140/100 mmHg

 HR : 92x/minute

 RR : 28x/minute

 T: 36.8o C
 Eye
 Anemic conjunctiva (-)
 Icteric sclera (-)

 Neck
 JVP 5-2 cmH2O

 Lung:
 Inspection: both symmetric at static and dinamic
 Palpation: fremitus left = right
 Percussion: sonor
 Auscultation: bronchovesicular, rales +/+, wheezing -/-

 Cor:
 Inspection: ictus not seen
 Palpation: ictus palpable I finger lateral LMCS ICS VI
 Percussion:
 Left border: I finger lateral LMCS ICS VI
 Right border: LSD
 Upper border: RIC II
 Auscultation: regular, murmur (-)
 Abdomen:
 Inspection: enlargement (-)
 Palpation: liver and spleen unpalpable
 Percussion : tympani
 Auscultation: bowel sound (+)

 Extremities:
 PhysiologicReflex +/+
 Pathologic Reflex -/-
 Edema (+/+)
Laboratory Findings

Examination Result
Hb 9.0 gr/dl
HT 27 %
WBC 9,260/ mm3
Platelet 136,000 mm3
RBG 158 mg/dl
Na/K/Cl 132/5.1/107 Mmol/L
Ureum / Creatinine 87/3.4 mg/dl
pH/pCO2/pO2 7.37/29/171
HCO3/BE/SO2 16.6/-8.5/100
Lac 0.8
Electrocardiography
Chest X Ray
Working Diagnosis
 ADHF Wet and Warm NYHA III
 DM type 2 Uncontrolled Normoweight
 Bronchopneumonia HCAP
 CKD Stage V cb Diabetic Nephropathy
 Pleural Effusion cb CHF
Therapy
 Rest/ Heart Diet II Low Protein 48 gr Diabetic Diet 1700 kkal
 IVFD NaCl 0.9% 12 h/kolf
 Drip Furosemid with syringe pump 5cc/h
 Ceftriaxone 2x1 gr iv (skin test)
 Levofloxacine 1x500 mg continued by 1x250 mg iv
 Folic acid 1x5 mg po
 N-acetyl sisteine 3x200 mg po
 Paracetamol 500 mg when needed
 Ramipril 1x2.5 mg po
 Simvastatin 1x20 mg po
 Nebulization fluimucil/6 h
 Nebulization farbivent/8 h
 Fluid balance
Plan

 Sputum culture
 Expertise Chest X Ray