DUTY REPORT

Friday, May 1st 2015

PHYSICIAN INCHARGE:
IB : dr. Intan, dr. Jaja, dr. Meli, dr. Rakhmi
II : dr. Vina, dr. Awan, dr. Arya, dr. Rizal
III : dr. Sri Sunarti, Sp.PD-KGer

Summary of Data base

Female /29 yo/w. 28
Chief Complaint : Shortness of breath

• A 29 years old woman was brought by her family to our ER because she suffered
shortness of breath since 5 days before admission that worsen in the last 1 day.
Shortness of breath worsen with activity, and also worsen when she lying down.
Since 5 months ago, she usually slept on 3 pillows in a half sitting position, the
shortness of breath occured even when she rest. She often awaken in the middle of
the night because of shortness of breath.
• She also complained about abdominal discomfort, nausea and vomiting since 1 day
before admission,she vomited 2 times, contained liquid and residual food about less
than a half glass of mineral water.
• She also complained about cough since 1 month ago, sometimes produced reddish
sputum.
• She was diagnosed with hypertension since 2 years ago, with history of frequent
headache
• She was diagnosed with Kidney failure since 1.5 years ago, performed hemodialysis
routinely 2 times/week and routinely consumed medication clonidin 3 x 0.15 mg,
ISND 3 x 5 mg and diltiazem 1 x 30 mg that she got from HD clinic to control her
blood pressure.

History of past illness

• No history of elevated blood glucose level before
History of family
• There were no family history with diabetes mellitus nor hypertension
Social History
She is a widow, doesnt have a child yet.

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Physical Examination

GCS 456 General Appearance which look moderately ill

BP 180/100 mmHg PR 96 tpm, regular RR 28 tpm, Tax 36.9 0 C
strong
Looked Normoweight BW : 50kg
Head Anemic (-), Icteric (-),
Neck JVP R +4 cm H2O 300
Thorax Cor Ictus invisible and palpable at ICS VI, 2 cm lateral MCL Sinistra
LHM ~ ictus,
RHM ~ SL D
S1, S2 single, murmur -
Lung Stem fremitus D = Sonor + + vv Rh - - Wh - -
S
++ vv - - - -
++ Bv BV + + - -
Abdomen Flat, bowel sound normal, liver span 10 cm, traube space is tympani,
shifting dullness +, supple
Extermities Leg edema (+), pale skin (+),

LABORATORY RESULTS

LAB RESULT NORMAL VALUE LAB RESULT NORMAL VALUE

Leukocyte 14.820 3,500- Sodium 130 136-145 mmol/l

10,000/µL
Hemoglobine 10.2 11.0-16.5 g/dl Potassium 3.69 3.5-5.0 mmol/L

MCV 92.00 80-97 µm3 Chloride 101 98-106 mmol/L

MCH 30.10 26.5-33.5 µm3
PCV 31.20 35-50% RBS 116 >200 mg/dL

Thrombocyte 217,000 150,000- Ureum 72.1 10-50 mg/dL

390,000/µl
SGOT 108 11-41U/L Creatinine 8.10 0.7-1.5 mg/dL

SGPT 144 10-41U/L Albumin 3.5-5.5 g/dL

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 BGA
Value with 02 2 tlpm normal
PH 7.42 7,35-7,45
PCO2 24.8 35-45
PO2 194.0 80-100
HCO3 16.0 21-28
O2 saturation 98.4 > 95%
Base Excess -8.7 -3 until +3
Conclussion
7,35-7,45 Metabolic acidosis fully compensated
ECG
 Sinus Rhythm, HR 110 tpm
 Frontal Axis : normal
 Horizontal Axis : clockwise rotation
 PR interval : 0.143”
 QRS complex : 0.09”
 QT interval : 0.34”
 P pulmonal
 Conclusion : Sinus rhythm with 110bpm, abnormality of right atrium
CXR
(not yet available)

Cue Clue PL I.Dx P.Dx P.Th/ P.Mo P.Edu

Female/29 YO 1. Shortness 1.1 Non NT-Pro Hemodialysis VS
Shortness of breath of breath dt cardiogenic BNP O2 8-10 lpm NRBM Subject
Hypertension since 2 impending 1.1.1 Uremic lung Fluid restriction ive
years ago ALO 1.2 Cardiogenic -Fluid intake 1,000- Fluid
Highest blood pressure 1.2.1 Heart 1,500cc/day balance
270/.. Failure St.C -Fluid balance (-) 500-1000
Cough for 1 months Fc.IV cc/day
with pink frothy Furosemide injection 3x40
sputum mg
PE:
BP 180/100 mmHg RR :
28 x/min
Conj anemi +,
Bilateral leg oedema
+/+
Rhonchi at basal of
both lung
Lab:
Ur/Cr 72.1/8.10
Female /29 yo/w.28 2.Hypertensi 2.1 Secondary Peroral: Subject
Shortness of breath on on 2.1.1.Renoparenc Diltiazem 1 x 30 mg ive . BP
Hypertension since 2 treatment hymal HT ISDN 3x5 mg
years ago 2.1.2 Clonidin 3x0.15 mg
Highest blood pressure Renovascular HT
270/.. 2.2 Primary HT
Diagnosed CKD since 1,

3
5 years ago
PE:
BP 180/100 mmHg RR :
28 x/min
Conj anemi +,
Bilateral leg oedema
+/+
Rhonchi at basal of
both lung
Lab:
Ur/Cr 72.1/8.10
Female 29 yo/ W28 3. CKD st 5 on Back up Hemodialisa Subject
CAPD ive
Shortness of breath (problem
Hypertension since 2 fluid CAPD)
years ago
Highest blood pressure
270/..
Diagnosed CKD since
1.5 years ago. On
routine HD and then
using CAPD since 2
months ago
PE:
BP 180/100 mmHg RR :
28 x/min
Conj anemi +,
Bilateral leg oedema
+/+
Rhonchi at basal of
both lung
Lab:
Ur/Cr 72.1/8.10
Female/29 YO 4. HF St C Fc 4.1 HHD Echocardio -Low sodium salt diet < 2 VS
Diagnosed IV 4.2.Uremic graphy, G/day, Compla
hypertension since 2 Cardiomyopathy -O2 8-10 lpm NRBM (as in
years ago above) Urine
Shortness of breath -Fluid balance as above produc
even when rest -control hypertension as tion
PND above
DOE
PE:
PE:
BP 180/100 mmHg RR :
28 x/min
Bilateral leg oedema
+/+
Rhonchi at basal of
both lung

Female/29 YO 5.Dyspepsia 5.1 PUD Endoscopy Inj. Metoclopramide 3 x 10 Subj.

Diagnosed CKD since Syndrome 5.2 Uremic mg VS
1.5 years ago. On gastropathy Inj. Omeprazole 1x 40 mg
routine HD and then
using CAPD since 2
months ago
Nausea and vomiting

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