DUTY REPORT

Saturday, 5 December 2015

PHYSICIAN INCHARGE
IA : dr. Nudi, dr. Yuni, dr. Reny
IB HCu : dr. Somarnam
IB CVCU : dr. Indra
IB ER : dr. Sasmithae, dr. Nando
Chief : dr. Nanik
Consultant : dr. Gadis N, SpPD FINASIM

Summary of Data base

Mr Fanus/69 yo/W.26
Chief Complaint: Shortness of Breath
Patient came to RSSA because shortness of breath since 3 days ago. SOB didn’t accopmanied
with position, gradually onset and worsened in 1 day before admission. Patient only sleep half sitting
with 3 pillow. Patient was long time bed riden since 1 month ago because felt very weak.
He was diagnosed with CKD since 1 month ago and was undergo hemodialise 4 times, but not yet had
routin schedule hemodialise.
Patient suffered cough since 3 days ago. Cough without sputum. He sometime also felt low grade
fever.
His hipertension and cardiac disease since 15 years ago and routin consume drugs. He routin control
at doctor 1 times a week and got digoxin, captopril, furosemid, and vasorbid.
Past Medical History & Medication: -
Social history: Patient didn’t work again, married, have 2 children. Never consume energy drink or
traditional poiton.
Family history: his father had hypertension.

Physical Examination

GCS 456 General Appearance : look moderately ill

BP 150/90 mmHg (ward) PR 98 tpm, regular RR 30 tpm, Tax 36,5 0 C
(tachycardi)
Looked Obese
Head Anemic (+), Icteric (-),
Neck JVP R + 5 cm H2O 300
Thorax Cor Ictus invisible, palpable ICS 5 MCL sinstra +2cm lateral RHM – sternal dextra
LHR –ictus cordis , double lumen cateter at dextra apex of thorax.
S1 – S2 reguler, murmur -
Lung Stem fremitus SS v v Rh - - Wh - -
D=S
SS bv bv + + - -

SS bv bv + + - -

Abdomen Soefl, epigastric pain (-),bowel sound normal, liver span 8 cm, traube space is
tymphanic, shifting dullness(-)
Extremities Leg edema (-),dry skin (-)

1
Laboratory Finding
Laboratory Result Normal Unit
Value
Hb 8.60 11,4-15,1 g/dL

Leucocyte 28.60 4.700-11.300 /µL

Hematocrit 26.90 38-42 %

Thrombocyte 154.000 142.000- /µL

420.000
MCV 87,60 80-93 fL

MCH 28.00 27-31 pg

MCHC 32,00 32-36 g/dL

Differential count 0.0/0.2/86.1/3.3/10.4 0-4/0-1/51- %

67/25-33/2-
5
SGOT 88 0-32 U/L

SGPT 60 0-32 U/L

RBS <200 mg/dL

Ureum 249.90 16,6-48,5 mg/dL

Creatinine 10.47 <1,2 mg/dL

Natrium 124 136-145 mmol/L

Kalium 4.80 3,5-5,0 mmol/L

Chloride 97 98-106 mmol/L

Osmolaritas 280-295 Mmol/L

PPT 27.4-28.6 second

INR 0,8 – 1,3

APTT second

Albumin 3.5-5.5 g/dL

Calsium 7.6 7.6-11.0 Mg/dL

2
 Phospor 5.9 2,7-4.5 Mg/dL

Plasma spesific gravity 1,025 – 1,029

BGA

Value O2 : NRBM 8 L/m suplementation Normal

pH 7.35 7.35 - 7.45
pCO2 19.4 35 - 45 mmHg
pO2 143.3 80 - 100 mmHg
HCO3 10.8 21 - 28 mmol/L
Base exess -15.0 (-3) – (+3)
Saturated O2 99.1 > 95%
Hb 9,6 g/dL
Conclusion Metabolic ascidosis fully compensated

ECG:

 Sinus rhythm, Heart rate 100 bpm

 Frontal Axis : Normal
 Horizontal Axis : Normal
 PR interval : 0,16”
 QRS complex : 0,04”
 QT interval : 0,34”
Conclusion : Sinus tachycardia with HR 100 bpm

CXR
• AP position, asymmetric, enough KV, less inspiration
• Soft tissue normal, bone normal
• Trachea in the middle
• Hemi diaphragm D and S dome shape
• Phrenico costalis angle D and S sharp
• Pulmo D and S: BVP increased
• Cor: site N, size CTR <59%,
Conclusion : Lung edema, cardiomegaly

3
Cue Clue PL I.Dx P.Dx P.Th/ P.Mo
Male 56 yo 1. 1.1 Uremic Lung Sputum O2 10 LPM NRBM Subjective,
Ax: Shortness 1.2 Hf Stage C fc IV SPS, vital sign
of Breath 1.3 Penumonia cultur BGA, SpO2
PE: spurum Urine production
BP: 140/90mmHg +
PR: 90 BPM sensitivi
RR: 30 TPM ty test
Ronchi at all area of
lung
Ictus cordis ICS 5 MCl
sinistra +2cm lateral

Lab:
Ur: 249.90 mg/dL
Cr:10.47 mg/dL

CXR: Lung edema +

cardiomegaly
Male 56 yo 2. Septic 2.1 Penumonia Blood O2 10 LPM NRBM Subjective,
Ax: condition HCAP culture Inj Cefoperazone vital sign
2.2 UTI and 2x1 gram IV
PE: sensitivi inj Levofloxasin 1
GCS 456 ty test x 250mg
BP: 140/90mmHg Sputum
PR: 90 BPM SPS,
RR: 30 TPM cultur
spurum
Lab: +
Leuco sensitivi
ty test
CXR: Lung edema +
cardiomegaly
Male 56 yo 3. 3.1 Volume Bj Negative fluid Subjective,
Ax: Hiponatre overload Plasma balance minus vital sign
mia 500cc/24 hour Urine production
PE: hipoosmol Inj Furosemide 3
ar x 500mg
Lab: hypervole
Na: 124 mmol/L mia
Osmol 253
Male 56 yo 3. HF 3.1 HHD echocar O2 10 LPM NRBM Subjective,
Ax: stage C fc 3.2 dilated diograp Negative fluid vital sign
IV cardiomyopathy hy balance minus Urine production
PE: 500cc/24 hour
BP: 140/90mmHg Valsartan 1 x
PR: 90 BPM 80mg
RR: 30 TPM

4
Ictus cordis ICS 5 MCl
sinistra +2cm lateral

Lab:
Ur: 249.90 mg/dL
Cr:10.47 mg/dL

CXR: Lung edema +

cardiomegaly
Male 56 yo 4. Anemia 4.1 chronic disease Blood O2 10 LPM NRBM Subjective,
Ax: Normochr 4.2 def EPO smear, Plan to inj EPO 3 x vital sign
om reticulos 3000 unit/weeks DL/3 days
PE: normocita ite Hemafort 1 x 1
BP: 140/90mmHg ir count
PR: 90 BPM
RR: 30 TPM
Pale conjungtiva
Lab:
Hb : 8.60 g/dL
MCV : 87.60 fL
MCH: 28.00 pg
Male 56 yo 5. 5.1 primary fundusc Low salt diet Subjective,
Ax: Hipertensi 5.2 secondary opy Valsartan 1 x vital sign
on grade 80mg
PE: 1
BP: 140/90mmHg
PR: 90 BPM
RR: 30 TPM

Lab:

Male 56 yo 6. CKD 6.1 Ht Renal diet 1700 Subjective,

Ax: stage 5 on Nephrosclerosis kkal/day, protein vital sign
HD 1-1,2 Urine production
PE: gram/kg/day, low
BP: 140/90mmHg salt <2gram/day
PR: 90 BPM Folic acid 1 1mg
RR: 30 TPM CaCo3 2x500mg
Lab: Plan to inj EPO 3 x
Hb : 8.60 g/dL 3000 unit/weeks
Ur: 249.90 mg/dL Hemodialisa as
Cr:10.47 mg/dL schedule
Ca: 7.6 mg/dL Negative fluid
Phospor: 5.9 mg/dL balance minus
500cc/24 hour