Morning &

Duty
Report
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

 Heri Sunoto/ Male/ 63 y.o /HCU - 15

Chief Complaint:
• Breathlessness increased since
1
3 days ago
Present Illness History

• Breathlessness increased since 3 day ago, had

been felt since 1 weeks before, interfered by
activity, but not by food or weather. Sleep
comfortable with 2-3 pillow. History wake-up
at midnight because of breathlessness (-)
• Fever since 3 days ago, no high, no chill, but
today fever not found
• Cough since 3 days ago, sputum, no bleed
Present Illness History

• Decrease of appetite since 1 week

ago
• Nausea since 1 week ago
• There is no history of bleeding
• Mixturition and defecation is normal
• Patient was referred from District
Hospital for next therapy
Past Illness History

• History of Hypertension since a year

ago, uncontrolled
• History of Diabetes Mellitus (-)

Family Illness History

• There is no family with the illness

Physical Examination

• General Appearance : Severe

• Consciousness level : CMC

• BP : 170/100 mmHg
• HR : 100 x/minute
• RR : 32 x/minute, kussmaul breathing
•T : 36,7 º C
• SaO2 : 97% on O2 10 L/mnt
• Eye
– Conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5+3 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus decrease since ICS V
– Percussion: dull since ICS V
– Auscultation: bronchovesicular, Rhonchi +/+, breath sound
decrease since ICS V
• Cor: VII
–Inspection : ictus is not seen
–Palpation : ictus is palpated at 1 finger lateral
LMCS ICS VI
–Percussion:
•Left border : 1 finger lateral LMCS ICS VI
•Right border: linea sternalis dextra
•Upper border: ICS II
–Auscultation: regular, murmur (-)
• Abdomen: VII
–Inspection : enlargement (-)
–Palpation : hepar and spleen is not palpable
–Percussion : shifting dullness (-)
–Auscultation : bowel sound (+) N

• Extremities:
–Oedema pretibia +/+
–Physiologic Reflex +/+
–Pathologic Reflex -/-
Laboratory
Items Value VII
Hb 7,6 gr/dl
Ht 22 %
WBC 11.170/mm3
Platelet 209.000/mm3
Diff. Count 0/0/0/91/4/5
PT/APTT 11,2/35,5
RBG 127 mg/dL
Ur/Cr 210/19,5 mg/dL (CKD epi: 15)
SOGT/SGPT 10/8
Na/K/Cl 131/6,6/105
BGA 7,25/19/160/8,1/-19,3/99
Chest X-Ray VII
ECG VII
Problems
• Breathlessness
• Pneumonia
• Kidney disease
• Heart failure
Working Diagnosis
• Chronic Kidney Disease Stage V with metabolic acidosis
compensated and hyperkalemi
• Congestive Heart Failure Stage C NYHA Fc III
• Community Acquired Pneumonia
• Pleural effusion cb CHF
• Moderate anemia normocytic normochrome cb
chronic disease
• Hypertension Stage II
• Syndrome dyspepsia type dysmotility
• Hypercoagulable state
Therapy
• Rest/liquid diet low salt low protein 48 gr
• O2 15 L/mnt via NRM
• IVFD Renxamin 250cc/24 hours
• Inj. Cefepime 3x1 gr (i.v)
• Inf. Levofloxacin 1x500mg IV (d-1)  then 1x250mg (d-2,dst)
• Drip furosemide 5mg/hours
• Drip meylon 150 mEQ in 300 cc NaCl 0,9% in 8 hours then meylon
150 mEQ in 300 cc NaCl 0,9% in 8 hours
• Paracetamol 3x500mg
• Asetilcistein 3x200mg
• Folic acid 1x5mg
• Bicnat 3x500mg
• Fluid balance
Plan
• Hemodialysis
• Culture Sputum
• Kidney USG
• Echocardiography