DUTY REPORT 13TH Febuary 2015

DUTY REPORTJune 24th 2015Resident on duty: dr. Cecep S. SoburGP on duty: dr. WidyaCo-Assistant on duty:Susasti and Fitriano1PATIENT RECAPITULATION3rd Floor:- Mrs. E (CKD on HD, pro CDL)- Mrs. D (GEA)4th Floor:- Mrs. T (CKD on HD pro CDPA, SIDA5th Floor:- Mrs. E (Ca. Mammae pro TACE)- Mrs. K (Ca. Mammae, low intake in psychiatric disorder)6th Floor:- Mr. S (Asites grade III, sirosis hepatis, CKD stage V)2PATIENTS IDENTITYName: Mr. SAge: 48 years oldJob: SoldierReligion: IslamMarital Status: MarriedRace: JavaneseAddress: Tanggerang3AnamnesisChief complain: Shortness of breath since 3 months before admission

4HISTORY OF PRESENT ILLNESSPatient has been feeling shortness of breath since 3 months before admission. The patient feel that it gets better if sleeping on his side and not much influenced by activity.

The patient also complained about the abdominal enlargement that happened since three years ago. At the beginning patient admitted that his abdomen started to enlarge since 7 years ago. The abdominal enlargement reduced significantly after he got the fluid from his abdomen being aspirated 3 years ago. Not long after that, the abdomen has been back enlarged and not much increasing until now.

5The patient admitted that he diagnosed hepatitis B and cirrhosis hepatic about 7 years ago. The initial complaint was jaundice, nausea, vomit and abdominal enlargement. Patient also diagnosed renal dysfunction since 7 years ago and has been on therapy hemodialisys since then.

There was no history of hematemesis, melena, or hematochezia.

Patient admitted that his urin output about a quarter less than the amount of water that he drank.

6Past IllnessDM (-)Lung disease (-)Heart disease (-)

7History of Family IllnessHT (-)Lung disease (-)Kidney disease (-)Allergy (-)

8General ExaminationHead: NormocephalEye: anemic conjunctiva (+/+), icteric sclera (-/-)Ears: discharge (-)Nose: septum deviation (-), discharge (-)Mouth: coated tongue (-), hyperemic pharynx (-), normal T1-T1, pale mouth mucosa (-), dried mucosa (-)Neck : JVP 5 2 cmH2O, lymph nodes enlargement (-)9Physical ExaminationGeneral State:Mildly sickConsciousness: GCS E4M6V5

Vital SignsBlood Pressure:150/100 mmHgHeart rate:86 bpm (regular)Respiratory Rate:20 times/minuteTemperature:36,7 oC

Body Weight:52 kgBody Height:165 cmBMI:20,5 (Normoweight)10Thorax: symmetric, intercostals retraction (-), gynecomastia slightly foundCORInspection: Ictus cordis (-)Palpation: heave (-), lift (-), thrill (-)Percussion:Right border: ICS V, linea parasternal dekstraLeft border : ICS V, linea midclavicularis sinistraHeart waist: ICS III, linea parasternal sinistraAuscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-) 11PULMOInspection : chest within normal shape, symmetries on static and dynamic state. Spider naevi (-)Palpation : tactile vocal fremitus both lungs were symmetries, chest expansion symmetriesPercussion : resonant both lungsAuscultation : vesicular breathing decreasing on the right side, rales (+/-), wheezing (-/-)

ABDOMENInspection: distended (d=90 cm) Palpation: soepel, hard nodul of the liver palpated but the liver edge difficult to palpate, spleen difficult to palpatePercussion: shifting dullness +, tympani to dullness Auscultation: BU + 13Extremities: warm, icteric (-), leukonychia +, CRT hard to evaluate, pitting edema (-), cyanosis (-), palmar erithema not found,14LABORATORY RESULTSExaminationResultNormal labHaematology:Hb7.113 - 18 g/dlHt2140 52 %Erythrocyte2.44.3 - 6.0 mil /ulLeukocyte34004800 - 10800/ulThrombocyte79000150000 - 400000/ulMCV8680 96 fLMCH2927 - 32 pgMCHC3432 36 g/dL15ExaminationResultNormal labCoagulation:PROTROMBIN TIMEControl10.1secondPatient11.610.2 12.2 secondAPTTControl35.1secondPatient44.229.0 40.2 secondINR1.000.8 -1.30(Without anticoagulation therapy)16ExaminationResultNormal labSGOT (AST)20< 35 U/LSGPT (ALT)10< 40 U/LAlbumin3.83.5 5.0 g/dLUreum7320 - 50 mg/dlCreatinin10.10.5 1.5 mg/dlSodium143135 147 mmol/LPotassium3.93.5 5.0 mmol/LChloride10295 105 mmol/L17ResumeMale, 48 years old came with chief complain shortness of breath since 3 months before admission. It worsen if laying down and better if sleep on his side.Patient has history of hepatitis B, chirrosis hepatica, hypertension, CKD on HD.From examination: Blood pressure 150/100 mmHg, anemic conjungtiva, ascites (+) diameter of abdomen 90 cm, liver nodul palpated, shifting dullness (+). Rhonkhi +/-Lab: ureum 73, creatinin 10,1

18Problem ListAscites grade IIICirrhosis hepatic Child-Pugh Score? with anemia normocytic normochromeChronic hepatitis BCKD stage V on HD

19AssesementShortness of breath suspect pleural effusion and due to anemiaBased on: Patients complaints: shortness of breath since 3 months before admission.PE: Respiratory rate 24 x/minutes. Rhonchi (+) on the right side. Hb: 7.1 mg/dL.

Diagnostic: Thorax rontgen

202. Ascites grade IIIBased on: Patients complaint: abdominal enlargement since 3 years agoPE: Abdomen diameter 90 cm, shifting dullness (+), dullness percussion found lower part of the abdomenDiagnostic: USG abdomenTherapy: Abdominal puncture (paracentesis) 213. Cirrhosis hepatic Child-Pugh Score? with anemia normocytic normochromeBased on: Patients history of chronic hepatitis BPE: liver nodul palpated, gynecomastia, leukonychia totalisDiagnostic: USG abdomen, Lab serum bilirubin, serum albumin to calculate CP score. Lab Hb 7.1, MCH-MCV-MCHC within normal limitTherapy:

224. Hipertensi stage IBased on:PE 150/100 mmHgTherapy: Captopril 25 mg 2 x 1

234. CKD stage V on HDBased on:Lab ureum 73 (increased), creatinin 10.1 (increased)GFR (140-48) x 52 = 6,5 72 x 10,1

24Prognosis Quo ad vitamdubia ad bonamQuo ad functionamdubia ad malamQuo ad sanationamdubia ad malam25