Duty report

January 29, 2018

Pajri , male, 55 yo, MW 3

Chief complain
Breathlessness increase since 1
days ago
 Present illness history
◦ Breathlessness increase since 1 days ago
influenced by activity, weather and food.
Sleep with elevated pillow (-)
◦ Naussea and vomit (-)
◦ Paleness since 1 week ago
◦ Fever since 3 days ago
◦ Cough since 3 days ago with sputum
◦ Urination was decrease since 3 weeks ago
◦ Black stool since 1 day ago.
◦ Bloody vomit (-)
◦ Pasient had been know suffer chronic kidney
disease and get routine HD 7 times

12/03/18
Physical Examination
level of consciousness : CMC

BP : 190 / 100 mmHg

HR : 100 x/minute

RR : 30 x/minute

T: 37,9 oC
 Eye
◦ Conjunctiva are anemic +/+
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation: bronchovesicular, Rh +/+, Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medial LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur (-)
 Abdomen:
◦Inspection: Enlargement (+)
◦Palpation: liver and spleen not palpable
◦Percussion: shiffting dullness (+)
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema +/+
Laboratory
Examination Result
Hb 6,3 g/dl
Leukosit 34.660 / mm3
Trombosit 126.000 / mm3
Ur / Cr 70 /6,8
GDS 149
Na / K / Cl 141/4,3/105
Hematokrit 20%
Ph 7,524
Pco2 24,1
Po2 46,4
Hco3- 20,1
Beecf -2,9
So2 87,1

12/03/18
Working Diagnose
ALO
Bronchopneumonia dupleks
(HCAP) wit respiratory failure type
1
CKD stg V on HD
Hypertension emergency
Moderate anemia normocytic
normochrom cb chronic disease
Melena cb uremic bleeding
Therapy
 rest / fasting 8 hr  protein 50 gr low salt II / NRM 02 10 L/i
 Bolus prosogan 80 mg continued with drip prosogan 80 mg
in 500cc nacl 0,9 % in 10 hr
 Drip herbesser 1 amp in 50 cc nacl 0,9 (syringe pump)
 Sucralfat syr 3xcth II
 Paracetamol 3x500mg
 Nebu flumucyl/8 hr
 Ceftazidime 2x 1 gr
 Levofloxacin 1x 500 mg
 Bicnat 3x 500 mg
 Folic acid 1x5 mg
 Transfussion PRC 1 unit
 Fluid balance
12/03/18