Morning &

Duty
Report
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

 Yetti/ female/ 60 y.o /HCU - 01

Chief Complaint:
• Breathlessness since 1 day ago
1
Present Illness History

• Breathlessness since 1 day ago, not interfered by

activity, food or weather. Sleep comfortable with 1
pillow. History wake-up at midnight because of
breathlessness (-)
• Cough since 1 month ago, sputum, no bleed
• Sweating in night since 1 month ago
• Fever since 2 days ago, no high, no chill, but today
fever not found
• Decrease of appetite since 1 week ago
• Nausea since 1 week ago
Present Illness History

• There is no history of
bleeding
• Mixturition and defecation is
normal
• Then referred from RS Ibnu
Sina
Past Illness History

• History of Diabetes Mellitus (+) since

20 year ago, routine controlled
• History of Hypertension (-)

Family Illness History

• There is no family with the illness

Physical Examination

• General Appearance : Severe

• Consciousness level : CMC

• BP : 120/70 mmHg
• HR : 104 x/minute
• RR : 26 x/minute
•T : 36,7 º C
• SaO2 : 91% on O2 15 L/mnt via NRM and O2 6L/mnt
via nasal canule
• Eye
– Conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus decrease since ICS VI hemisphere dextra
– 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 V
–Percussion:
•Left border : 1 finger lateral LMCS ICS V
•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 8,6 gr/dl
Ht 24 %
WBC 15.090/mm3
Platelet 293.000/mm3
Diff. Count 0/3/0/91/3/3
PT/APTT/D-Dimer 11,8/31/9698
RBG 69 mg/dL
Ur/Cr 248/3,7 mg/dL
Alb/glb 1,9/2,3
SOGT/SGPT 37/15
Na/K/Cl 129/5,4/104
BGA 7,40/23,5/145,4/14,8/-10,2/99,3
Chest X-Ray VII
ECG VII
Problems
• Breathlessness
• Pneumonia
• Kidney Failure
Working Diagnosis
• Sepsis cb Hospital Acquired Pneumonia high risk
• Acute on CKD with hyperkalemia
• Mild anemia normocytic normochrome cb chronic
disease
• High risk VTE
• Hypoalbumin ec renal loss
• Hypertension st II cb essensial
• Ulkus pedis (S) post debridement
• HF st B NYHA FC II
Differential Diagnosis
• Sepsis cb Infection of operative wound
• AKI st III cb renal cb sepsis
Therapy
• Rest/liquid diet low salt low protein 48 gr
• O2 15 L/mnt via NRM
• IVFD Renxamin 250cc/24 hours
• Inj. Meropenem 3x1 gr (i.v)
• Inf. Levofloxacin 750mg /48 hours
• Inf. Albumin 25% IV extra
• Paracetamol 3x500mg
• Asetilcistein 3x200mg
• Folic acid 1x5mg
• Bicnat 3x500mg
• Candesartan 1x8mg
• Kalitake 3x1 sachet
• Fluid balance
Plan
• Urinalysis
• Culture Sputum, urine, and blood
• Kidney USG
• Hemodialysis