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DUTY REPORT

Saturday, July 16th 2015

Physician in Charge :
1A : dr Intan, dr Rina, dr Jaja
II CVCU : dr Nina
II HCU : dr Rere
II UGD : dr Zen, dr Kries
Chief : dr Eva
Consultant : dr Heri Sutanto, SpPD

Mr M. Juri/42 yo/Ward 26
HISTORY TAKING : Heteroanamnesa with his daughter
CHIEF COMPLAIN : Shortness od breath
HISTORY OF PRESENT ILLNESS
Patient suffered from shortness of breath since a week prior to admission. The shortness of breath was
triggered when he did daily activity but didn’t relieve in resting position. Patient said that he was slept with 2-3
pillows, for almost every night he woke up because of shortness of breath. He also complained bilateral leg swelling
since that time.
He also complained about productive cough, yellowish sputum, blood (-) since a month ago, worsened in
the last a week, accompanied with low grade fever. He also complained about night sweating since a month ago. His
bodyweight decreased 5 kg in a month.
He complained about nausea and vomiting since a week ago, about 3-4x/day, contained residual food and
fluid, about ½ glass each. He had decreased of appetite, with only ate 1-2 times a day and sometimes consumed
milk.
He had been diagnosed kidney disease since 2 months ago at RSSA, had been performed hemodyalisa since
a month ago, 1x/week, every monday. He had been diagnosed hypertension since 2 months ago at RSSA, blood
pressure about 200/… mmHg. He took amlodipine 1x10 mg and valsartan 1x160 mg.
HISTORY OF PAST ILLNESS : -
FAMILY HISTORY : His father had hypertension
SOCIAL HISTORY : he is married, having 3 chidren, he is a “tukang kayu”, history consumed traditional potion and
NSAID since 1 year ago 1x/, he smoked 6 bars/day since youth until 2 months ago.

PHYSICAL EXAMINATION

General Appearance: looked severely ill Looked normoweight

GCS: 356 BP: 140/100 mmHg on drip furosemide PR: 112 times/minute RR: 36 times/minute Tax : 36.4 C

Head Anaemic conjunctiva (+)

Neck JVP: R + 4 cm H2O in 30° position

Wall Within normal limit

Chest Ictus invisible, palpable at ICS V 2 cm lateral MCL S


Heart RHM ; LHM
S1S2 single, mumur – gallop -
Symetric Stem fremitus D=S bv bv Rh + + Wh - -

bv bv + + - -
Lung

v v + + - -

Abdomen Soefl, Bowel sound (+) N, traube space thymapani, shifting dullness (-), liver span 9 cm flank pain +/+

Bilateral leg edema


Extremities
Urine production 20cc/hour

LABORTATORY FINDINGS

Laboratory Result Normal Value Unit

Hb 6.6 11,4-15,1 g/dL

Leucocyte 5010 4.700-11.300 /µL

Hematocrit 20.70 38-42 %

Thrombocyte 259000 142.000-420.000 /µL

MCV 93.2 80-93 fL

MCH 27.8 27-31 pg

MCHC 31.9 32-36 g/dL

Differential count 0/0.2/77/10.8/12 0-4/0-1/51-67/25-33/2-5 %

SGOT 66 0-32 U/L

SGPT 18 0-32 U/L

RBS 117 <200 mg/dL

Ureum 123.9 16,6-48,5 mg/dL

Creatinine 7.49 <1,2 mg/dL


Ca 11.5 7.6-11.0
Phospat 4.8 2.7-4.5
Natrium 132 136-145
Kalium 5.76 3.5-5.0

Chlorida 112 98-106


Troponin I 7.35 – 5.7 – 3.02 Positive > 1
CK-NAC 411 -- 467 – 451 39-408
CKMB 69 – 50 -- 49 7-25

ECG
Sinus tachycardia, heart rate 120 beats/minute
Frontal axis :N
Horizontal axis :N
PR interval : 0,16 seconds
QRS interval : 0,08 seconds
QT interval : 0,32 seconds
Conclusion: Sinus tachycardia, heart rate 120 beats/minute

CXR
• AP position, asymmetry, enough KV, enough inspiration
• Trachea in the middle
• Soft tissue and bone normal
• Hemidiaphragma right and left are dome shaped
• Costophrenical angle right and left are sharp
• CTR: 56%, ictus embedded, site N
• Pulmo : BVP increase, fibroinfiltrat at all area lung D/S, cotton wool appearance
Conclusion: Cardiomegaly + Uremic lung + Pneumonia

BGA
BLOOD GAS ANALYSIS WITH OXYGEN 10 LITERS

pH 7.39 7,35-7,45

pCO2 28.5 35-45

pO2 53.3 80-100

HCO3 17.4 21-45

BE -7.8 (-3) – ( +3)

O2 saturation 86.1 >95


BGA conclusion Respiratory failure type 1

URINALYSIS
10 x
1.015
SG

Epithelia 1.0
6.0
PH

Cylinder -
Negative
Leucocyte

Hyaline -
Negative
Nitrite

Granular -
3+
Protein

Negative
Keton

40 x
Negative
Glucose

Erythrocyte 30(eumorphyc)
3+
Blood

Leukocyte 1.8
Negatif
Bilirubin

Crystal -
Negatif
Urobilinogen

Bacteria 28.9x103/ ml
Problem Oriented Medical Record

Planning
Re Problem List Initial Diagnosis Planning Therapy Planning Monitoring
Diagnosis

Male/ 78 yo/ w26 1. Shortness of 1.1. Respiratory Sputum culture Bed rest semifowler position Monitoring:
Anamnesis: breath failure type 1 Sensitivity test O2 10-12 lpm Jackson Rees CBC
SOB precipitating FAB Insert NGT S, VS
PND + DOE + factor infection SPS culture Fluid diet 6x200 cc/day
Chronic productive cough, 1.2. ADHF Echocardiography Inf levofloxacine 1x250 mg iv
yellowish sputum precipitating Paracetamol 3x500 mg po if Education
Low grade fever, night factor infection needed Disease, treatment,
sweating 1.3. Uremic lung prognosis
HT on treatment 1.4. Acute lung
CKD on routine HD infection
Bilateral leg swelling 1.4.1.
Pneumonia
Physical examination: HCAP
GCS 356 1.4.2 Lung TB
BP: 140/100 mmHg on drip secondary
furosemide infection
PR: 112 bpm
RR: 36 tpm
Tax: 36.4 degree celcius
JVP R+4 cm H2O
cardiomegaly
Rhonki all area lung D/S
UOP 20 cc/hour
Bilateral leg edema +

Laboratory:
UL (erythrocyte 30 hpf,
eumorphyc; proteinuria 3+)
Hb 6.6
Leucocyte 5010
neutrophyl 77.1%
Ur 123.9 Cr 7.49
Troponin I 7.35 – 5.7 – 3.02
CK-NAC 411 -- 467 – 451
CKMB 69 – 50 -- 49
CXR : Cardiomegaly +
Uremic lung + Pneumonia
ECG : Sinus tachycardia,
heart rate 120
beats/minute
BGA : respiratory failure
type 1
Male/ 78 yo/ w26 2. ADHF 2.1. HHD Echocardiography Bed rest semifowler position Monitoring:
Anamnesis: precipitating 2.2. Uremic O2 10-12 lpm Jackson Rees Ur Cr
SOB factor infection cardiomyopathy Drip furosemide 20 mg/hour Fluid balance
PND + DOE + Negative 500 cc fluid balance S, VS
Chronic productive cough, Valsartan 1x80 mg po
yellowish sputum HD cito
Low grade fever, night Education
sweating Disease, treatment,
HT on treatment prognosis
CKD on routine HD
Bilateral leg swelling

Physical examination:
GCS 356
BP: 140/100 mmHg on drip
furosemide
PR: 112 bpm
RR: 36 tpm
Tax: 36.4 degree celcius
JVP R+4 cm H2O
cardiomegaly
Rhonki all area lung D/S
UOP 20 cc/hour
Bilateral leg edema +

Laboratory:
Leucocyte 5010
neutrophyl 77.1%
Ur 123.9 Cr 7.49
Troponin I 7.35 – 5.7 – 3.02
CK-NAC 411 -- 467 – 451
CKMB 69 – 50 -- 49
CXR : Cardiomegaly +
Uremic lung + Pneumonia
ECG : Sinus tachycardia,
heart rate 120
beats/minute

Male/ 78 yo/ w26 3. Acute lung 3.1. Pneumonia Sputum culture Bed rest semifowler position Monitoring:
Anamnesis: infection HCAP and sensitivity O2 10-12 lpm Jackson Rees S, VS
SOB 3.2 Lung TB test Antibiotic as above CBC
PND + DOE + secondary FAB
Chronic productive cough, infection SPS culture Education
yellowish sputum Disease, treatment,
Low grade fever, night prognosis
sweating
Decreased of bodyweight

Physical examination:
PR: 112 bpm
RR: 36 tpm
Tax: 36.4 degree celcius
Rhonki all area lung D/S

Laboratory:
Leucocyte 5010
neutrophyl 77.1%
CXR : Cardiomegaly +
Uremic lung + Pneumonia

Male/ 78 yo/ w26 4. CKD st 5 on 4.1. HT Biopsi Kidney Bed rest semifowler position Monitoring:
Anamnesis: routine HD nephrosclerosis O2 10-12 lpm Jackson Rees S, VS
SOB 4.2. GNC Drip furosemide 20 mg/hour Ur cr
Nausea and vomiting Negative 500 cc fluid balance Fluid balance
HT on treatment Renal fluid diet 6x200 cc/day, low
CKD on routine HD sal < 2g/day Education
Bilateral leg swelling Valsartan 1x80 mg po Disease, treatment,
HD cito prognosis
Physical examination:
GCS 356
BP: 140/100 mmHg on drip
furosemide
PR: 112 bpm
RR: 36 tpm
Anemia conjunctiva
JVP R+4 cm H2O
cardiomegaly
Rhonki all area lung D/S
UOP 20 cc/hour
Bilateral leg edema +

Laboratory:
UL (erythrocyte 30 hpf,
eumorphyc; proteinuria 3+)
Hb 6.6
Leucocyte 5010
neutrophyl 77.1%
Ur 123.9 Cr 7.49
eGFR 6.9
K 5.76
P 4.8
CXR : Cardiomegaly +
Uremic lung + Pneumonia
ECG : Sinus tachycardia,
heart rate 120
beats/minute

Male/ 78 yo/ w26 5. Hypertension 5.1. Primary Abdominal USG Low salt diet as above Monitoring:
Anamnesis: on treatment 5.2. HT Antihypertension as above BP
HT on treatment renoparencymal
CKD on routine HD Education
Bilateral leg swelling Disease, treatment,
prognosis
Family history of
hypertension

Physical examination:
GCS 356
BP: 140/100 mmHg on drip
furosemide
PR: 112 bpm
JVP R+4 cm H2O
cardiomegaly

Laboratory:
Ur 123.9 Cr 7.49
eGFR 6.9
CXR : Cardiomegaly

Male/ 78 yo/ w26 6. Anemia 6.1. Deficiency Reticulocyte Tranfusion PRC 1 pack durante Hb level
Anamnesis: Normochrome eritropoeti count HD until Hb>8 g/dL
SOB Normocytair 6.2. Chronic SI Education
HT on treatment inflammation TIBC Disease, treatment,
CKD on routine HD 6.3. Diminished prognosis
Decreased of appetite RBC survival

Physical examination:
GCS 356
BP: 140/100 mmHg on drip
furosemide
PR: 112 bpm
RR: 36 tpm
Anemia conjunctiva
JVP R+4 cm H2O
cardiomegaly
Rhonki all area lung D/S
UOP 20 cc/hour
Bilateral leg edema +

Laboratory:
UL (erythrocyte 30 hpf,
eumorphyc; proteinuria 3+)
Hb 6.6
MCV 93.2
MCH 27.8