Duty Report

April 4th, 2021

 Jusni 46y.o, Female, HCU9
• Cc:
 Breathlessness Increased since3 days ago.

• Present Illness History

 Breathlessness Increased since 3 days ago. , was not affected by activity, weather and
food.
 Fatique since 1 week ago
 Decrease of appetite since 1 week ago
 Fever since 1 week ago continuously ,sweating (-) shivering (-)
 Cough since 1 week ago with white phlegm (+) bloody(-)
 Swollen since 1 week ago, especially the legs and stomach
 Nausea (-), vomit (-)
 History of bleeding: Gum bleeding (-) Skin bleeding/ bluish on the skin (-),
nosebleed(-) black defecation before( -) black vomit before (-)
 Defecation and Micturition was was normal
• History of HT (+) since 6 months ago
• History of DM (+) since 6 months ago
 Physical Examination
• Consciousness level: CMC

• BP : 150/70 mmHg

• HR : 98 x/min

• RR : 22x/minute

• T: 37,9 oC
• Skin : ptechiae (-)
• Eye
• Conjunctiva anemic (+)
• Sclera icteric (-)

• Neck
• JVP 5-2 cmH20

Lymph Node: unpapble

• Lung:
• Inspection: symetric left=right
• Palpation: fremitus left=right
• Percussion: sonor
• Auscultation: bronchovesicular, rales +/+ wheezing -/-
COR
• Abdomen:
• Inspection: enlargement (+)
• Palpation: shifting dullness(+)
Hepar and spleen unpalpable
• Percussion: tympani
• Auscultation: bowel sound (+) normal
• Flank : knocking and pressure pain at CVA -/-
• Extremities:
• Edema +/+
• Physiologic Reflex +/+
• Pathologic Reflex -/-
 Laboratory
Hb 5,9 g/dl Ur 313 mg/dl Albumin 1,3 g/dl pH 7,32
Leukocy 5990 Cr 8,0 mg/dl Globulin 2,9 g/dl PCO2 20
te /mm3
Platelet 157.000 / EGFR 6 SGOT 24 u/L PO2 148
mm 3
ml/min/1
,73m2
HT 17 Na 129 SGPT 13 U/L SO2 99
mmol/L
Diff 0/0/68/24/ K 5,0 mmol/ PT 11,4 s HCO3 10,3
Count 8 L

MCV 75 Cl 109 APTT 29,2 s BEecf -15,8

mmol/L
MCH 27 Ca 7,0 mg/dl INR 1,03

MCHC 35 Reticul 1,49 D-Dimer 2190 RBG 80

ocyte mg/dl
Ro Thorax
ECG
ECG INTERPRETATION
Irama Sinus P N
Tachycardi
a

HR 112 PR <0,20
Axis RAD QRS <0,04
I,AVF
+/+ :N
+/-: LAD
-/+: RAD

R/S VI <1 ST Isoelectric

RVH
SV1+RV6 <35 T Tall -
LVH
 Working Diagnose
• CKD Stage V ec Nephropathy Diabetic with Metabolic
Acidosis
• Hospital acquired pneumonia with Bilateral Pleural Effusion
• Severe anemia normocytic normochrome ec chronic disease
• Hypercoagulable state
• Type II DM Controlled overweight
• Hypoalbuminemia
• Hyponatremia ec hemodilution
 Therapy
• Rest/ Diabetec Diet 1700 kcal Low salt II Low Protein 48 gr/ O2 3 L
• IVFD NaCL 0,9% 500cc/24 hours
• Inj Cefepime 3x1 gr iv
• Inj levofloxacin 1x750 g iv (days I ) 1x250 mg iv ( days 2)
• Drip meylon 150 mEq in 350 cc NaCl 0,9% / 8 hours Drip meylon 150 mEq in 350 cc NaCl 0,9% /
8 hours
• Albumin transfusion 25% 100cc extra iv
• Inj heparin 2x5000 iu sc
• Folic acid 1x5 mg po
• Bicnat 3x500 mg po
• N-Acethylsistein 3x200 mg po
• Paracetamol 3x500 mg po
• Amlodipin 1x5 mg po
• Candesartan 1 x8 mg po
• Ramipril 1x 2,5 mg po
• Fluid balance
Plan

•PRC Tranfusion 2 unit

•Sputum culture
•Abdominal Ultrasound
•Kidney Ultrasound
•Hemodialysis