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Resident on duty: dr. Evan
Coass on duty: Zikril & Aris
DUTY REPORT 23RD JANUARY 2015
EMERGENCY UNIT
RECAPITULATION PATIENT
Floor Patient (8)
3 -
4 Mrs. S, 45 years old, CKD Stage V, DM Type 2Mr. M, 52 years old, Fever on SIDATn. L, 47 years old, dyspeptic syndrome, DM Type 2
5 Mrs.N, 32 years old, Typhiod fever
6 -
PATIENT’S IDENTITY
• Name : Mrs. S
• Sex : Female
• Medical Record : 800133
• Age : 45 years old
• Religion : Moslem• Marital Status : Married• Work : housewife• Address : South Kalimantan
ANAMNESIS
Autoanamnesis on 23rd January 2015 at 17.00 PM
Chief Complaint : stomach and legs are swelling for 1 month before admission
Additional Complain: Nausea and breathless if the stomach is swelling
CURRENT ILLNESS
• Stomach and legs are swelling for 1 month before admission. Stomach and legs felt swelling intermittent, more noticeably enlarged abdomen when the patient urinate a little. When the patient's abdomen enlarges only given eucalyptus oil and then feel better.
• 2 weeks before admission patient gets Lasix medication and vitamins kidney. After taking medication Lasix patient felt his stomach is not too large. After the results of laboratory blood kreatini out, the patient stated that chronic kidney disease patients not currently receiving treatment.
CURRENT ILLNESS
• 6 months before admission had been treated for 12 days and in the diagnosis of AKI. During the treatment received the drug insulin, albumin and vitamin hepatic correction. Having treated patients rarely control.
• The patient also had uncontrolled diabetes mellitus type 2 since last 5 years. Get therapy 1x30mg glurenom, but patients taking the drugs only when blood sugar is high.
• The patient also has uncontrolled hypertension since last 5 years. Get therapy 1x5mg amlodipin, but patients only take medication only when high blood pressure.
PAST ILLNESS
• 7 months ago had cataract surgery OS.• 4 years ago the patient surgery amputation on his in digiti
pedis dekstra 3.4 and 5.• heart and lung illnes (-)
• Dad patients suffering from type 2 diabetes mellitus• Ren,heart, and lung illnes (-)
FAMILY ILLNESS
HABITS AND LIFESTYLE
• There were no history of smoking, alcoholic drinking, taking drugs.
PHYSICAL EXAMINATION
VITAL SIGNS• General State : Moderate Sickness• Consciousness : Compos Mentis• Blood Pressure : 210/90 mmHg• Heart Rate : 68 x/minute• Respiratory Rate : 24 x/minute• Temperature : 36.3oC• Body Weight : 62 kg• Body Height : 160 cm• BMI : 24,21 (normoweight)
PHYSICAL EXAMINATION
General Examination• Head : Normocephal
• Eye : anemic conjunctiva (-/-), icteric sclera (-/-)• Ears : normotia, discharge (-)• Nose : septum deviation (-), discharge (-)• Mouth : oral trush (-), leukoplakia (-)
• Neck : lymph nodes enlargement (-)• Thorax : symmetric, intercostal retraction (-)
• Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-)
• Pulmo : vesicular breathing sounds, ronki (-/-), wheezing (-/-)
• Abdomen : distended (+), bowel sound within normal limit, timpani, shifting dullnes (+)
Extremities : warm, inferior extremities pitting edema (+), clubbing (-), cyanosis (-), CRT < 2 seconds.
DIAGNOSTIC PLANS
RESULT NORMAL RANGE
routine hematology :
Hb 12,4 13 - 18 g/dl
Ht 37 40 – 52 %
Erythrocyte 4,2* 4.3 - 6.0 mil /ul
Leukocyte 8180 4800 - 10800/ul
Thrombocyte 275.000 150000 - 400000/ul
MCV 89 80 – 96 fL
MCH 30 27 - 32 pg
MCHC 33 32 – 36 g/dL
LABORATORIUM (19-01-2015)
RESULT NORMAL RANGE
Clinical Chemistry :
Natrium 137 135 – 147 mmol/L
Kalium 4,1 3.5 – 5.0 mmol/L
Klorida 113* 95 – 105 mmol/L
Ureum 131* 20-50 mg/dl
Kreatinin 5,4* 0,5-1,5 mg/dl
Albumin 2,5 * 3,5 – 5,0 g/dl
Blood Sugar (fasting) 129* 70-100 mg/dL
Blood Sugar (2 hours PP) 185* < 140 mg/dL
JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
Urinalisis
Warna Keruh* Kuning
Kejernihan Keruh* Jernih
pH 5,5 4,6-8,0
Beratt Jenis 1,015 1,010-1,030
Protein Positif 3* Negatif
Glukosa Negatif Negatif
Bilirubin Negatif Negatif
JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
Urinalisis
Nitrit negatif negatif
keton negatif negatif
Urobilinogen negatif negatif
eritrosit 2-3-3 <2/LPB
leukosit 20-15-20* <5/LPB
Epitel Positif 1 positif
Lain – lain Bakteri +/positif 1 * Negatif
ULTRASONOGRAPHY ABDOMEN
• CFR grade II bilateral
• Ascites (+)
RESUME
• Patient female, 45 y.o., come with complaints stomach and legs are swelling for 1 month before admission. More noticeably enlarged abdomen when the patient urinate a little. Complaints accompanied by Nausea and breathless if the stomach is swelling. The patient also has uncontrolled diabetes melitus type 2 and uncontrolled hypertension since last 5 years. Fisical Examination found: Blood Pressur 210/90 mmHg, shifting dullnes (+), inferior extremities pitting edema (+). Laboratory found Ureum increase 131 mg/dL, Kreatinin increase 5,4 mg/dL, Albumin decrease 2,5 g/dL, Blood Sugar (fasting) increase 129 mg/dL and Blood Sugar (2 hours PP) increase 185 mg/dL. Ultrasonography Abdomen CFR grade II bilateral and ascites.
PROBLEMS LIST
1. CKD stage V
2. Diabetes Melitus Type 2
3. hypertensive urgency
4. Hypoalbuminemia
ASSESSMENT1. CKD stage V
anamnesis: stomach and legs are swelling for 1 month before admission. More noticeably enlarged abdomen when the patient urinate a little. Complaints accompanied by Nausea and breathless if the stomach is swelling.
Examination : shifting dullnes (+),inferior extremities pitting edema (+).
Laboratory : Ureum increase 131 mg/dL, Kreatinin increase 5,4 mg/dL
UGS Abdomen :CFR grade II bilateral and Ascites (+)
Plan : prepare HD: complete peripheral blood test, calcium, fosfate, pt, aptt
ASSESSMENT2. Diabetes Melitus Type 2
Anamnesis: The patient also had uncontrolled diabetes mellitus type 2 since last 5 years.
Laboratory : Blood Sugar (fasting) 129 mg/dL and Blood Sugar (2 hours PP)185mg/dL
Plan :
ASSESSMENT
3. hypertensive urgency
Anamnesis : The patient also has uncontrolled hypertension since last 5 years.
Examination : Blood Pressure 210/90 mmHg
ASSESSMENT
4. Hypoalbuminemia
Laboratory : Albumin 2,5 g/dL
PROGNOSIS
• Qua ad vitam : Dubia ad bonam
• Qua ad functionam : Dubia ad malam
• Qua ad sanationam : Dubia ad malam
THANK YOU
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