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GENERAL WARD DUTY REPORT

8th March 2016

RESIDENT ON DUTY:
- dr. FACHRULL
- dr. YULIANTO

COASS ON DUTY:
- ELSA
- OKI
Patient Recapitulation

1. Mr. P CDL bleeding obs, CKD


2. Mr. A Fever day 4 obs susp. DHF gr I
3. Mrs. K CKD on HD
4. Mr. H Fever day 4 obs susp. DHF gr I
5. Mr. R Fever day 4 obs susp. DHF gr I
6. Mr. S Fever day 4 obs susp. DHF gr I
7. Mr. S Fever day 6 obs susp. DHF gr I
Patients Identity

Name :K
Age : 40 y.o
Sex : Female
Religion : Moslem
Address : East Jakarta
Marital Status : Married
Med. Rec. No : 826586
Anamnesis

Autonamnesis

Chief Complaint :
Shortness of breath for 2 weeks
History of Present Illness
Patient came to the ward with feeling
shortness of breath for 2 weeks. It was going
whole day and worsened by activity.
2 weeks before admission patient had done 8
haemodialysis at RS Sumedang, she was sent
to RSPAD due to limitation of the equipment.
3 months before admission: she complained
about nausea, vomit, shortness of breath, dry
cough and itchy skin on whole body. Those
complaint were getting worse each day and
she felt her stomach and feet were getting
swollen.
Her apetite within normal limit, she limits her
drinks 600 cc/day.
Defecate within normal limit, urinate 250
cc/day.
She had done HD before came to the ward.
Now, she felt sleep better with 2-3 pillows.
PND (-)
History of Past Illness
HT (+) since 5 years ago
DM (-), Heart Disease (-)

Family History
HT (+) her grandmother
Heart Disease (-), Kidney Disease (-)

Medication History
Amlodipin 1x10mg, not regularly
Physical Examination
General State : Moderatly Ill
Conciousness : Compos Mentis

Vital Sign
- BP : 140/120 mmHg - RR : 28 tpm
- HR: 112 bpm, Reg - T : 36,5oC

Body Weight : 50 Kg
Body Height : 155 Cm
BMI : 20,83 Kg/m2 (Normorweight)
Head : Normocephal
Eye : Anemic Conjunctiva +/+, Icteric
Sclera -/-
ENT : Within Normal Limit
Neck : JVP are unevaluable due to her pain
from the CDL, Lymph nodes enlargement (-)
Thorax
- Pulmo
I : Symmetry movement from both hemithorax
P : Vocal Fremitus within normal limit,
symmetry expansion from both hemithorax
P : Sonor
A : Vesicular +/+, Rales +/+, Wheezing -/-

- COR
I : Ictus Cordis was seen
P : Ictus Cordis was palpable on ICS V sinistra
midclavicula line
P : No cardiomegaly
A : Regular 1st and 2nd heart sound, Murmur (-),
gallop (-)
Abdomen:
- I : rounded abdomen
- A : Bowel Sound (+) within normal limit
- Pa : No organomegaly, skin turgor within
normal limit
- Pe : Shifting dullness (+), CVA tenderness -/-

Extremities : Warm, CRT < 2 sec, pitting


edema (+) both lower extremities
Lab Result
Lab Result
Normal value
examination (08/03/2016)
Haemoglobyn 10.5 13-18 g/dL
Hct 31 40-52 %
Eritrocyte 3.5 4,3-6,0 juta/L
Leukocyte 7820 4.800-10.800/L
Trombocyte 238000 150.000-400.000/L
MCV 89 80-96 fL
MCH 30 27-32 pg
MCHC 34 32-36 g/dL
Result
Lab Examination Normal Value
(08/03/2016)
Ureum 158 <20 50 mg/dL
Creatinin 10.6 0.5 1.5 mg/dL
Random Blood Sugar 95 < 140 mg/dL
Na 139 135 147 mmol/L
K 4.9 3.5 5.0 mmol/L
Cl 102 95 105 mmol/L
Result
Blood Gas Analysis Normal Value
(08/03/2016)
pH 7.309 7.37 -7.45
pCO2 27.2 33 34 mmHg
pO2 151.4 71 104 mmHg
HCO3 13.8 22 -29 mmol/L
BE -10.2 (-2)-3 mmol/L
O2 sat 99.0 94 98 %
Resume
Patient came to the ward with feeling
shortness of breath for 2 weeks. It was going
whole day and worsened by activity.
2 weeks before admission patient had done 8
haemodialysis at RS Sumedang, she was sent
to RSPAD due to limitation of the equipment
3 months before admission: nausea (+), vomit
(+), shortness of breath (+), dry cough and
itchy skin on whole body (+). Stomach and
feet were getting swollen (+)
Her apetite within normal limit, she limits he
drinks 600 cc/day.
Defecate within normal limit, urinate 250
cc/day.
She had done HD before came to the ward.
Now, she felt sleep better with 2-3 pillows.
PND (-)
History of hypertension since 5 years ago.
PE result : Anemic conjunctiva on both eyes,
Rales on both hemithorax, shifting dullness
(+) on abdomen, pitting edema on lower
extremities.
Lab result : Normochromic Normocytic
anemia, increasing of ureum and creatinin,
metabolic acydosis
List of Problem

1. Dyspnoe obs. ec CKD dd/ CHF dd/ Pleural


effusion
2. Hypertension gr I
3. Normochromic Normocytic Anemia
Discussion

1. Dyspnoe obs. ec CKD dd/ CHF dd/ Pleural


effusion
A(x) : Patient came to the ward with feeling
shortness of breath for 2 weeks. It was going
whole day and worsened by activity. 2 weeks
before admission patient had done 8
haemodialysis at RS Sumedang, she was sent
to RSPAD due to limitation of the equipment
Her apetite within normal limit, she limits her
drinks 600 cc/day, urinate 250 cc/day.
She had done HD before came to the ward,
History of hypertension since 5 years ago.
PE result : Anemic conjunctiva on both eyes,
Rales on both hemithorax, shifting dullness
(+) on abdomen, pitting edema on lower
extremities.
Lab result : Normochromic Normocytic
anemia, increasing of ureum and creatinin,
metabolic acydosis
Diagnostic Planning : ECG, Chest x-ray,
Echocardiography, BNP
Therapy planning :
O2 NC 3 lpm
Inj. Furosemid 2 x 3 Amp IV
P.O Bicnat 3 x 1 tab
CKD Risk Factor of
Etiology

Metabolic Chronic Haemostatic &


Disorders Inflammationv Thrombosis
Disorders

Diabetic
Electrolyte Anemia
Acidosis Metabolic Thrombosis
Nutrition
Disturbance

Conservative
Management

Severity & Disturbance


of Haemodynamic

Haemodyalisis
Haemodyalisis

Commorbid with Heart Failure

Search another ethyology,


Continue HD Check level Heart Failure
infection, tuberculosis

Maintanance of Quality of LIfe


2. Hypertension gr I
A(x): hystory of Hypertension since 5 years ago.
PE BP = 140/120 mmHg
Diagnostic Planning : ECG, chest x-ray
Therapy Planning : P.O Amlodipin 1x 10 mg
3. Normochromic Normocytic Anemia
A(X) : hystory of CKD for 3 months
PE : CA +/+
Laboratory result : Hb 10,5 g/dl, MCV MCH
MCHC within normal limit
Diagnostic planning : peripheral blood swab,
reticulosit count
Therapy planning :-
Prognosis

Quo ad Vitam : Dubia ad Bonam


Quo ad Sanationam : Dubia ad Malam
Quo ad Functionam : Dubia ad Malam
Thank You