Duty report

December 5th, 2018

Susanti ,Female, 54 yo, FW 12
Chief complain
Fatigue increased since 1 weeks ago
Present illness history
◦ Fatigue increased since 1 weeks ago
◦ Patient look pale since 2 weeks ago, patient has bee k
nown with hemolitic anemia since 1 months ago
◦ Fever (-)
◦ Cough (-)
◦ Shortness of breath (-)
◦ patien has been know with CKD stg V and get routin
e hemodyalisis in sungai dareh hospital
◦ Defecation was normal

12/09/2021
 Past illness history
 History of heart disease (+) since 4
years ago
History of DM (+) since 2 years ago

12/09/2021
 Physical Examination
Consciousness level: CMC

BP : 180/90 mmHg

HR : 86 x/min

RR : 20 x/minute

T: 36,7 C
 Eye
◦ Conjunctiva are anemic (+/+)
◦ Sclera icteric (-/-)
 Neck
◦ JVP 5+0 cmH20
Lung:
◦ Inspection : simetris
◦ Palpation : fremitus same both of lung
◦ Percussion : sonor both of lung
◦ Auscultation : vesikuler +/+, Rhonki -/-, wheezing -/-
 Cor:
◦ Inspection : ictus not palpable
◦ Palpation : ictus 2 finger lateral lmcs RIC VI
◦ Percussion:
 Left border : 2 finger lateral lmcs RIC VI
 Right border : linea sternalis dextra
 Upper border : ric II
◦ Auscultation: pure rhythm
 Abdomen:
◦Inspection : enlargement (-)
◦Palpation : liver and spleen unpalpable
◦Percussion : thympani
◦Auscultation : bowel sound (+) normal

CVA : knocking pain (-)

 Extremities:
◦edema -/-
Hb 6,2 g%
WBC 3220/mm3
platelet 166.000/mm3
Ht 18%
Ur/cr 48/5,9 mg/dl
Na/K/Cl/Ca 139/3,9/109/7,9 mmol/L
SGOT/SGPT 81/72
ECG
CXR

12/09/2021
Working Diagnose
CKD Stage V cb Nefrosclerosis
hipertension on routine hemodilysis
 Hypertension heart disease
 Hemolitic autoimun anemia
 DM type II controlled overweight
 Moderate anemia cb chronic disease
Therapy
Rest/ Soft diet DD 1500 kkal low prote
in 60 gr low salt
IVFD Nacl0,9% 500 cc/24 hours
 Bicnat 3 x 500 mg PO
 Folic acid 1 x 5 mg PO
 Amlodipin 1 x 10 mg PO
 Candesartan 1 x 16 mg PO
 Glicuidon 1 x 30 mg PO

12/09/2021
Plan
Kidney sonography
Hemodialysis

12/09/2021