8/10/2019 Duty Report Tn. Jumain. W27.

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DUTY REPORT

29 NOVEMBER 2014

BY: Wan Adi Surya and Elita Riyu

Summary ofData Base

Physical Examination Laboratory Findings Cues and Clues Problem List Initial Diagnosis PDx PTx Pmo

Ny.

Jumain/M/43yo

/W27

Chief

complaint:

SOB and

Weakness

Patient

suffered from

shortness of

breath since 1

weeks before

admision, but

after doing

hhaemodialysis

, shortness of

breath is

decreased.

Patient is

scheduled to do

HD once a

week. Its

patient 3rd

schedule forHD. Since 2

days before

admisions,

pasien suffered

form weakness,

lossing of

Vital Sign:

GCS 456

BP: 90/60 mmHg

HR: 88 bpm, reguler

RR: 24x/m

T.ax: 35,7 C

General appearance:

Looked Moderatelly Ill

Compos Mentis

Head:

Pale conjungticva (-/-)

Ikteric sclera (-/-)

Neck:

JVP R+2cm H2O

Lymphnode enlargement (-)

Inserted double-lumen cath.

Thoraks:

Heart:

Ictus invicible, palpable at ICS

6 2cm lateral MCL S,

LHM~Ictus, RHM~ SL D, S1S2

single bising sistolik gr. 4/6

LPS ictus

Lung:Spontan Symetrically

breathing, Stem Fremitus

D=S,

Vesicular breath sound,

Rhonchi (+) basal, Wheezing (-

)

(30/11/2014)

Na: 123

K: 7,16

Cl: 98

(30/11/2014)

Hb: 6,80

RBC: 2,36

WBC: 15.850

HCT: 20,50

PLT: 304000

MCV: 86,90

MCH: 28,80

Diff Count:

2,7/0,1/87,6/2,8/6,8

GDS: 99

Ur/Cr: 400,20/29,3

Uric acid: 13,7

OT/PT: 18/9

Albumin: 3,04

Ca: 5,0

Ph: 17,4

Chol.total: 109

TG: 145

HDL: 21

LDL:54HbsAg: Negatif

Anti HCV: Negatif

Male/ 43 yo/ w.27

Ax: Suffered from

SOB since 1 weeks

before admission.

Worse at last 3 day.

Newly diagnosed

with CKD 2 weeks

ago

BP: 90/60 mmHg

HR: 88 bpm, reguler

RR: 24x/m

Lab findings:

Ur: 400,20 mg/dL

Cr: 29,3 mg/dL

1. SOB 1.1 Uremic lung

1.2 HC st.C fc.3

CXR photo

Blood Gas Artery

(BGA)

Electro

Cardiography

Cardiac marker

O2 2-4 lpm NC

Soft kidney diet

1900 kkal, protein

0,6-0,8g/kgBB/day

PO:

NaBic 3x500 mg

CaC03 3x100 mg

Continue HD as

scheduled

Subjective, VS

Urine production

Male/ 43 yo/ w.27

Ax: Suffered from

SOB since 1 weeks

before admission.

Worse at last 3 day.

Newly diagnosed

with CKD 2 weeks

ago

Lab findings:

Ur: 400,20 mg/dL

Cr: 29,3 mg/dL

Ca: 5,0

Ph: 17,4

2. CKD st. 5 routinely

HD

2.1 HT

nephrosclerotic

USG Abdomen O2 2-4 lpm NC

Soft kidney diet

1900 kkal, protein

0,6-0,8g/kgBB/day

PO:

NaBic 3x500 mg

CaC03 3x100 mg

Continue HD asscheduled

Subjective, VS,

Urine production

8/10/2019 Duty Report Tn. Jumain. W27.

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appetite,

nausea (+), but

no vomitting,

feeling of

fullness. Patient

is diagnosed

with HT since 3years ago and

consume

captopril as

antihypertentio

n. DM istory

was denied.

Patient is a

married man

with 3 children,

works as a

driver. Patient

smoke arround

2 pack a day,

and theres

history of jamu-

jamuan dinking

Abdomen:

Flat, soefl, BS(+)normal,

Traube space typanic, Liver

span 8cm

Extrimities:

Warm extrimities, Edema (-)

Male/ 43 yo/ w.27

Ax:

General weakness

Cold acral

BP 70/50 at HD

90/70 in wardPR 64 bpm at HD

80 bpm in ward

3. Shock condition 3.1 Septic shock

3.1.1 Pneumonia CAP

3.2 Cardogenic shock

3.3 Hipovolemic

shock

Drip NE 1amp in

100cc NS, starts

from 4 dpm, add on

4 dpm/15minute up

to MAP>70 then

maintenance

Subjective, VS,

urine production

Male/ 43 yo/ w.27

Ax:

Nausea since 2 days

ago, feeling of

abdominal fullness,

loss of appetite

Lab findings:

Ur: 400,20 mg/dL

Cr: 29,3 mg/dL

4. Dyspepsia syndrome 4.1 Uremic

gastropathy

4.2 PUD

Inj:

Metoclopramide

3x10 mg intravena

PO:

Omeprazole 2x20

mg

Amlodipin 1x12 mg

Subjective, VS,

Male, 43 yo

Ax: general

weakness

PE: Pale conjungtiva

Lab findings:

Hb: 6,8 gr/dL

MCV: 86,9 fL

MCH: 28,8 pg

MCHC: 31,30 g/Dl

5.Anemia NN 5.1 Related to CKD

5.1.1 Defisiensi Epo

Blood smear Confirmed

diagnosis

Epo transfusion is

planned

Sujective, VS

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