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EMERGENCY UNIT

DUTY REPORT
23RD JANUARY 2015
Resident on duty: dr. Evan
Coass on duty: Zikril & Aris

RECAPITULATION PATIENT
Floor

Patient (8)

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4

Mrs. S, 45 years old, CKD Stage V, DM Type 2
Mr. M, 52 years old, Fever on SIDA
Tn. L, 47 years old, dyspeptic syndrome, DM Type 2

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Mrs.N, 32 years old, Typhiod fever

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PATIENT’S IDENTITY • Name : • Sex : • Medical Record • Age : • Religion : • Marital Status • Work : • Address : Mrs. S Female : 800133 45 years old Moslem : Married housewife South Kalimantan .

00 PM Chief Complaint : stomach and legs are swelling for 1 month before admission Additional Complain: Nausea and breathless if the stomach is swelling .ANAMNESIS Autoanamnesis on 23 rd January 2015 at 17.

more noticeably enlarged abdomen when the patient urinate a little. . When the patient's abdomen enlarges only given eucalyptus oil and then feel better. After taking medication Lasix patient felt his stomach is not too large. the patient stated that chronic kidney disease patients not currently receiving treatment. Stomach and legs felt swelling intermittent. • 2 weeks before admission patient gets Lasix medication and vitamins kidney.CURRENT ILLNESS • Stomach and legs are swelling for 1 month before admission. After the results of laboratory blood kreatini out.

• The patient also had uncontrolled diabetes mellitus type 2 since last 5 years. but patients only take medication only when high blood pressure. but patients taking the drugs only when blood sugar is high. • The patient also has uncontrolled hypertension since last 5 years.CURRENT ILLNESS • 6 months before admission had been treated for 12 days and in the diagnosis of AKI. Having treated patients rarely control. Get therapy 1x5mg amlodipin. albumin and vitamin hepatic correction. . Get therapy 1x30mg glurenom. During the treatment received the drug insulin.

and lung illnes (-) .PAST ILLNESS • 7 months ago had cataract surgery OS.4 and 5. • 4 years ago the patient surgery amputation on his in digiti pedis dekstra 3. • heart and lung illnes (-) FAMILY ILLNESS • Dad patients suffering from type 2 diabetes mellitus • Ren.heart.

alcoholic drinking. taking drugs.HABITS AND LIFESTYLE • There were no history of smoking. .

3oC : 62 kg : 160 cm 24.21 (normoweight) .PHYSICAL EXAMINATION VITAL SIGNS • General State • Consciousness • Blood Pressure • Heart Rate • Respiratory Rate • Temperature • Body Weight • Body Height • BMI : : : : Moderate Sickness Compos Mentis : 210/90 mmHg 68 x/minute : 24 x/minute : 36.

intercostal retraction (-) • Cor: regular 1st and 2nd heart sound.PHYSICAL EXAMINATION General Examination • Head : Normocephal • Eye : anemic conjunctiva (-/-). ronki (-/-). gallop (-) • Pulmo : vesicular breathing sounds. wheezing (-/-) . leukoplakia (-) • Neck : lymph nodes enlargement (-) • Thorax : symmetric. discharge (-) • Mouth : oral trush (-). discharge (-) • Nose : septum deviation (-). murmur (-). icteric sclera (-/-) • Ears : normotia.

bowel sound within normal limit. cyanosis (-). inferior extremities pitting edema (+). CRT < 2 seconds. timpani.• Abdomen : distended (+). shifting dullnes (+) Extremities : warm. . clubbing (-).

000 150000 .0 mil /ul Leukocyte 8180 4800 .2* 4.32 pg MCHC 33 32 – 36 g/dL routine hematology : .4 13 .10800/ul Thrombocyte 275.18 g/dl Ht 37 40 – 52 % Erythrocyte 4.6.400000/ul MCV 89 80 – 96 fL MCH 30 27 .3 .DIAGNOSTIC PLANS LABORATORIUM (19-01-2015) RESULT NORMAL RANGE Hb 12.

5 – 5.5 mg/dl Albumin 2.5-1.RESULT NORMAL RANGE Natrium 137 135 – 147 mmol/L Kalium 4.5 * 3.0 mmol/L Klorida 113* 95 – 105 mmol/L Ureum 131* 20-50 mg/dl Kreatinin 5.4* 0.5 – 5.1 3.0 g/dl Blood Sugar (fasting) 129* 70-100 mg/dL Blood Sugar (2 hours PP) 185* < 140 mg/dL Clinical Chemistry : .

5 4.6-8.015 1.010-1.JENIS PEMERIKSAAN HASIL NILAI RUJUKAN Warna Keruh* Kuning Kejernihan Keruh* Jernih 5.030 Protein Positif 3* Negatif Glukosa Negatif Negatif Bilirubin Negatif Negatif Urinalisis pH Beratt Jenis .0 1.

JENIS PEMERIKSAAN HASIL NILAI RUJUKAN Nitrit negatif negatif keton negatif negatif Urobilinogen negatif negatif eritrosit 2-3-3 <2/LPB leukosit 20-15-20* <5/LPB Epitel Positif 1 positif Bakteri +/positif 1 * Negatif Urinalisis Lain – lain .

ULTRASONOGRAPHY ABDOMEN • CFR grade II bilateral • Ascites (+) .

More noticeably enlarged abdomen when the patient urinate a little..o.5 g/dL. come with complaints stomach and legs are swelling for 1 month before admission. inferior extremities pitting edema (+). Ultrasonography Abdomen CFR grade II bilateral and ascites.RESUME • Patient female. The patient also has uncontrolled diabetes melitus type 2 and uncontrolled hypertension since last 5 years. Kreatinin increase 5. Fisical Examination found: Blood Pressur 210/90 mmHg. Albumin decrease 2. Laboratory found Ureum increase 131 mg/dL. shifting dullnes (+). Complaints accompanied by Nausea and breathless if the stomach is swelling. Blood Sugar (fasting) increase 129 mg/dL and Blood Sugar (2 hours PP) increase 185 mg/dL . 45 y. .4 mg/dL.

PROBLEMS LIST 1. 4. 2. 3. CKD stage V Diabetes Melitus Type 2 hypertensive urgency Hypoalbuminemia .

ASSESSMENT 1. Complaints accompanied by Nausea and breathless if the stomach is swelling. Laboratory : Ureum increase 131 mg/dL.inferior extremities pitting edema (+). CKD stage V anamnesis: stomach and legs are swelling for 1 month before admission. pt. More noticeably enlarged abdomen when the patient urinate a little.4 mg/dL UGS Abdomen :CFR grade II bilateral and Ascites (+) Plan : prepare HD: complete peripheral blood test. calcium. Kreatinin increase 5. aptt . Examination : shifting dullnes (+). fosfate.

Diabetes Melitus Type 2 Anamnesis: The patient also had uncontrolled diabetes mellitus type 2 since last 5 years. Laboratory : Blood Sugar (fasting) 129 mg/dL and Blood Sugar (2 hours PP)185mg/dL Plan : .ASSESSMENT 2.

ASSESSMENT 3. Examination : Blood Pressure 210/90 mmHg . hypertensive urgency Anamnesis : The patient also has uncontrolled hypertension since last 5 years.

Hypoalbuminemia Laboratory : Albumin 2.ASSESSMENT 4.5 g/dL .

PROGNOSIS • Qua ad vitam : Dubia ad bonam • Qua ad functionam: Dubia ad malam • Qua ad sanationam : Dubia ad malam .

THANK YOU .