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Morning Shift Report Friday, 05 Oktober 2013 dr.

Kriestian

Physi 1A 1B II III

ian !n "harge# : dr.Kriestian, dr Rini, dr Eldi : dr. dr Betty, dr Nanik : dr. Vindrya : dr. Syifa Mustika, SpPD

Su ary !f Data Base Male / 35 yo/ ward 26 Chief complain : shortness of breath Patient suffered from shortness of breath since 1 day before admission, without accompanied by cou h, and happened e!en he was on rest" #e must sit to reduce his $%&"#e also suffered from nausea and !omitin , didn't want to eat since 1 day before" &oth of his le was swellin since 2 wee(s a o" Past medical history : Patient was dia nosed renal failure since March 2)13 and ot routinely #* e!ery +ednesday and $aturday" 2 days before admission he had already ot #* and relie!ed, but worsenin a ain" Patient ot hypertension since he was 1,th years old $ocial history : #e often drun( traditional potion and dru s e!erytime he felt tired in order to do his -ob"

P"ysi#al E$a
BP : 1%&'1(& #ead

inati!n
.C$ /56 RR + ./ tp 0a$ : ./.123

.eneral appearance loo(ed se!erely ill )* PR +1&, -p re*ular ,

Pale con-uncti!a 012, icteric sclera 032,

pupil isocor 3mm43 mm, round, reacti!e to li ht

5ec( Chest #eart:

67P 8 15cm#2% 3) de ree 9ctus in!isible and palpable at 9C$ 79 ::; ;#M < ictus 8#M: $; $1, $2 sin le, murmur 032

;un :

$ymmetric, $= *>$, 7 9! 8h 3 3 +h 3 3 b!9b! 11 3 3 b!9b! =lat , soefl, bowel sound 012 normal, li!er span ? cm, traube space tympani, shiftin dullness 032 Cold acral, edema 1/1

:bdomen @Atremities

4a-!rat!ry 5indin* 6!kt!-er 7t", (&1.8


4AB #emo lobin MC7 MC# ;eu(ocyte @o/&as/5eu/;i mf/Mon PC7 Frombocyte $.%F $.PF VA49E ,"?) 6?"B 2B"3 ?"3/) N:RMA4 11,0-16,5 g/dl 80-96 fl 26,5-33,5 pg 3.500-10.000/L 4AB 8&$ Creum Creatinin e VA49E 1?3 ,B,B ,"1 12B /"?5 1)) 3,6/ N:RMA4 < 200 mg/dl 10-50 mg/dL 0,7-1,5 mg/dL 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L

)/)"2/,3"5/1 0-4/0-1/51-67/255atrium 5"B/1)"2 33/2-5 23D 366"))) 22 26 35-50% 150.000390.000/L 11-41U/L 10-41U/L Ealium Chlorida :lbumin

B;A Ph pC%2 pa%2 #C%3 &@ %Ay en saturation

NI4AI ,,5, ,2,1 12?,3 2),? 31,6 BB,1D Metabolic acidosis uncompensated

N:RMA4 ,,353,,/5 353/5 ?)31)) 2132? 0332 G 032 HB5D

E3;

$ynus rhytm , #8 116 bpm =rontal :Ais : normal #oriIontal :Ais : C+8 P8 inter!al : ),16J K8$ compleA : ),)?J KF inter!al : )"/) 3!n#lusi!n : sinus ta#"i#ardy 1&/ -p "$R #

, 4V)

AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue normal, Phrenicocostalis angle D is blunt/S is sharp, Hemidiaphragm D dome shape, Sinistra is covered by cardiac shadow , Pulmo cotton woll appearance in all lung area !or site normal, cardiac waist "#$, ape% embedded ,si&e !'( )*+ ,!onclusion enlargement, uremic lung, pleural effusion de%tra heart

"%& '() "*%& Ma-e.3/ yo S-. even ta/e a rest History of H' since 01 years ago Had !KD since A year ago and got 2% routine HD P3 Pale con4ungtiva 5VP (61cmH27 .P 017/027 mmhg 8ctus at 8!S V8 AA9 sinistra Pulmo rhonchi in medial and basal lung area 3%tr edema 3!: sinus tachycardy and 9VH !;( heart enlargement with uremic lung,

P*

!)+

P)+ 5F pro &5P

P,+ %2 ?31) lpm 58&M 9n- furosemide /)m 3/)m 3) #* ele(tif

PMo $, 7$ Crine prod, .C$

P edu @ducat ed about diseas ed, terapi and pro no sis

1" $hortness 1" 1 5on Cardio enic of breath 1"1"1 Cremic lun 1"1"2 ;un infection 2"1 Cardio enic 1"1"1" #= sta e c =c97

pleural efusion <ale/=+ yo S-. even ta/e a rest History of H' since 01 years ago Had !KD since A year ago and got 2% routine HD >ausea and vomiting P3 Pale con4ungtiva 5VP (61cmH27 .P 017/027 mmhg 8ctus at 8!S V8 AA9 sinistra Pulmo rhonchi in medial and basal lung area 3%tr edema 3!: sinus tachycardy and 9VH !;( heart enlargement with uremic lung *ab # Hb +,? @r +ABA !r +,0 e:fr 1,1* Male/ 3, yo #ad been dia nosed #F since 15 years a o P@ : 67P 815 cm #2% &P : 15)/12) mmh 9ctus at 9C$ 79 MC; sinistra @C. : sinus tachicardi an ;7# CM8 : #eart =B Hypertensi stage 2 =B0primary =B2 secondary (enoparenchima l hypertension fundoscopy 9ow salt diet Diltia&em =%=7mg S VS $alt restrict ion Foo( mdicat ion routine lly 2" CE* st 7 on routine #* 0in adeLuate #*$ 2B0 H' nephrosclerosis 2B2 :>! @S: abdomen (enal diet 0A77 /cal/ day 9ow salt C 2 gr/day Protein 7,*#7,? gr//g.D/day .alance negative 177 cc Drip Eurosemid 07 mg/ hour Hemodialysis elective S VS @-P =luid restrict ion $alt restrict ion #emod yaliIe punctu al

enlar ement Male/ 3, yo #ad been dia nosed #F since 15 years a o P@ : 67P 815 cm #2% &P : 15)/12) mmh 9ctus at 9C$ 79 MC; sinistra @C. : sinus tachicardi an ;7# CM8 : #eart enlar ement <ale/ =+ yo 9oo/ pale Hb +B? <!V *?BA <!H 2AB= @r +ABA !r +,0 e:fr 1,1* <ale/=+yo >ausea and vomiting @r +ABA !r +,0 e:fr 1,1* *B dyspepsia syndrome *B0 uremic gastropathy *B2 P@D 3ndoscopy 8n4 metoclopramide = % 07 mg iv Po omepra&ole 2 % 27 mg Sub4, VS FBHE st ! fc 8V /"1 #ipertension #eart *isease /"2 Cremic cardiomyopa thy echocardiograp hy -2 ?#07 lpm >(.< 8n4 Eurosemide F7mg# F7mg#7 !aptopril = % 21 mg S Vs @-P ;imitat ion of acti!iti es

1B Anemia >#>

*B0 dt >o 2 *B2 !hronic disease *B= Deff Ee

'reat underlying disease

!.!

#i h iron diet