Duty Report

April 4th, 2021

 Ernawati 37y.o, Female, HCU8
• 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
 Heartburn increased since 1 week ago, was affected by food, was not affected by activity
and rest. spread (-)
 Nausea since 1 week ago, vomit (-)
 Fever since 3 days ago continuously ,sweating (-) shivering (-)
 Cough since 3 days ago with white phlegm (+) bloody(-)
 History of bleeding: Gum bleeding (-) Skin bleeding/ bluish on the skin (-), nosebleed(-)
black defecation before( -) black vomit before (-)
 Defecation and Micturition was was normal
 The patient is known to have CKD and has received Hemodialysis since 2 years ago.
• History of HT (-)
• History of DM (-)
 Physical Examination
• Consciousness level: CMC

• BP : 110/62 mmHg

• HR : 88 x/min

• RR : 22x/minute

• T: 37,2 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: Epigastric tenderness (+)
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 6,2 g/dl Ur 253 mg/dl Albumin 3,3 g/dl pH 7,49
Leukocy 7950/mm3 Cr 18,4 Globulin 3,1 g/dl PCO2 21,8
te mg/dl
Platelet 195.000/m Na 130 SGOT 15 u/L PO2 76,1
m 3
mmol/L
HT 18 K 4,0 mmol/ SGPT 11 U/L SO2 95,3
L
Diff 0/0/80/9/1 Cl 98 PT 11,9 s HCO3 17,1
Count 1 mmol/L

MCV Ca 8,7 mg/dl APTT 30,7 s BEecf -6,3

MCH RBG 106 INR 0,89

mg/dl
MCHC Reticul 2,09
ocyte
Ro Thorax
ECG
 Working Diagnose
• Hospital acquired pneumonia with Hypoxemia
• CKD Stage V ec Glomerulo Nephritis Chronic on
hemodialysis
• Moderate anemia normocytic normochrome ec chronic disease
• Syndrom Dyspepsia Type Like Ulcer
 Therapy
• Rest/ Gastrric Diet II Low Protein 60 gr/ O2 5 L
• IVFD Easprimer 250 cc/24 hours
• Inj ceftriaxon 2x1 gr iv
• Inj levofloxacin 1x500 g iv (days I ) 1x250 mg iv ( days 2)
• N-Acethylsistein 3x200 mg po
• Paracetamol 3x500 mg po
• Folic acid 1x5 mg po
• Bicnat 3x500 mg po
• Amlodipin 1x5 mg po
• Ramipril 1x 2,5 mg po
• Lansoprazole 1x30 mg po
• Sucralfate 3x15 ml po
• Fluid balance
Plan
• PRC Tranfusion 1 unit
• Sputum culture
• Hemodialysis