Duty Report 28 April 2014

5/25/2018 Duty Report 28 April 2014

1/32

1. Kisman , Male 39 yo,HCU 11

Cc : decrease of conciousness since 1 day ago

Present Illness history :

decrease of conciousness sice 1 day ago,

nausea since 5 days ago, vomit (+) contentfood , bloody vomit (-)

decrease of apetite (+) since 5 days ago

patient has been hospitalized in RSUD painanfor 3 days and diagnosed with CKD stage V andhas tranfution 4 unit. patient was refered toM.Djamil hospital caused by decrease of

conciousness.


2/32

2

- breathelessness since 2 days ago, no influencewith activity, weather and food.

past illness history ;

- history of hypertention not known

- history of chest pain not known

- history of diabetes not known


3/32

Physical Examinationconsc :delirium GA : bad

BP: 160/90 mmHg HR: 104x/RR: 40x/ T:37,2 0C

Eye : anemic (+)/(+), icteric (-)neck : JVP 5+0 cmH2OLymp nodes: no enlargmentLung: normochest,simetris,sonor,

bronkovesikuler, rales (+/+), wh (-/-)Heart: ictus unseen,ictus was palpable at RIC VI 1

finger lateral LMCS ,regular rhtym, gallop(-)


4/32

5/20/2014

abdomen : flat ,hepar and lien was not

palpable, tympani, bowel sound (+)

extremity : RF +/+, RP -/-, edema +/+


5/32

LABORHb : 6,6 gr.dl

Ht : 20%

leukosit : 10.700/mm3

trombosit : 187.000/mm3

GDS : 153 mg/dl

ureum /creatinin : 299/15,9 mg /dl

TKK : 5,2

protein urine : +++ (3)


6/325/20/2014

working diagnose :

CKD stage V ec nefroskelorosis hypertention

with uremic ensefalopathy and asidosis

metabolic

dd/: CKD stage V ec PNC. CHF fc II LVH RVH sinus tacikardi rhytm ec

HHD

. hyponatremia ec hemodilution

dd/ : hyponatremia ec low intake


7/325/20/2014

therapy: rest/ NGT diet/ MC DJ II / O2 3 liter / i IVFD Nacl 3% 12 hours/kolf ( 2 kolf) IVFD easprimer 500 cc/24 hours inj ca glukonas 1x1 ampul (extra) inj. lasix 1x1 ampul asam folat 1x 5 mg bicnat 3x500 mg

corection meylon 200 meq in 200 cc Nacl 0,9% rapid tears

crossmatch tranfution PRC 1 unit post lasix


8/325/20/2014

PLAN

consult to ophtalmologist

exp.rontgen thorax

check hepatitis marker

check faal hepar

echocardiography


9/32

1. Wirman Wahid , Male 66 yo,HCU 7

Cc : breathlessness increase since 1 day ago


breathlesness increase since 1 day ago, it has been felt since 5

days ago, no influence with activity, weather and food.

patient has been known CKD and has been undergone hemodialisasince 8 months ago every tuesday and thursday

cough since 5 days ago, sputum (+)

fever since 1 day ago, not high, not chill, and not sweat a lot

decrease of apetite since 5 days ago. history of sleep with 2 pillows (+)


10/3210

- swollen at both of legs (+) since 2 weeks

ago

- defecation and mixturition normally

- history of diabetes melitus (+) since 34years ago, uncontrolled regularly.

- history of hypertention (+) since 32 years

ago, uncontrolled regularly.


11/32

Physical Examination

consc :CMC GA : moderate

BP: 190/100 mmHgHR: 88x/

RR: 22x/

T:370C

Eye : anemic (+)/(+), icteric (-)

neck : JVP 5+1 cmH2O

Lymp nodes: no enlargment

Lung: normochest,simetris,sonor,bronkovesikuler, rales (+/+), wh (-/-)

Heart: ictus unseen,ictus was palpable 1 finger lateralLMCS RIC VI,regular rhtym,gallop(-)


12/325/20/2014

abdomen : hepar was palpable 1 finger bac,

blunt edge, flat, pain (-), lien S0

tympani, bowel sound (+)

extremity : RF +/+, RP -/-, edema +/+


13/32

LABOR

Hb : 9,5 gr.dl

Ht : 29%

leukosit : 6.200/mm3


Na : 137 mmol/lkalium : 3,9 mmol/l

clorida : 103 mmol/l

GDS : 85 mg/dl


TKK : 8,5


14/325/20/2014

working diagnose :

CHF fc III LVH RVH sinus rhytm ec ASHD

CKD stage V ec nefropati diabetikum on HD

routine

bronkopnemonia duplex (CAP)

DD/

CHF fc II LVH RVH sinus rhtym ec HHD

susp. lung TB duplex


15/325/20/2014

therapy:

rest/ DJ II RP 45 gram DD 1700 kkal

IVFD easprimer 500 cc/24 hours

inj. lasix 1x1 ampul

inj. ceftriaxone 1x2 gram (iv) skin test

asam folat 1x 5 mg

bicnat 3x500 mg

ambroxol syrup 3xcth II

glurenorm 1x30 mg

amlodipin 1x10 m

candersartan 1x 8mg

catheter urine --> fluid balance


16/325/20/2014

PLAN

exp.rontgen thorax

echocardiography

hemodialisaUSG ginjal


17/32

zenko binter, Male 32 yo,petri

Cc : breathlessness increase since 1 day ago


breathlesness increase since 1 day ago, no influence withactivity, weather and food.

cough since 2 weeks ago sputum(+), blood (-)

fever since 2 weeks ago, high, chill (-), sweat (-)

decrease of body weight (+) since 2 months ago, but patient dontknow how much is

decrease of apetite since 2 weeks ago,


18/3218

- history of sweat at night (+) since 2 weeks

ago- candidiasis oral (+) since 2 weeks ago- patient was refered to M.Djamil hospital

from RST bukittinggi, and has been

hospitalized for 7 months and has doneRapid test HIV reaktif- history of free sex (+) at 2013- history of consumed narkoba drugs (-)

- tatoo (+)- history of consumed OAT (-)- history of DM (-)- history Hypertention (-)


19/32



BP: 150/90 mmHgHR: 120x/

RR: 40x/

T:380C

Eye : anemic (+)/(+), icteric (-)

neck : JVP 5-2 cmH2O


Lung: simetris statis and dinamis, fremitus increase at rightlung, sonor, bronkovesikuler rh+/+, wh -/-

Heart: ictus unseen,ictus was palpable 1 finger medialLMCS RIC V,regular rhtym,gallop(-)


20/325/20/2014




extremity : RF +/+, RP -/-, edema -/-


21/32

LABOR

Hb : 6,9 gr.dl

Ht : 21%leukosit : 21.400/mm3


GDS : 129 mg/dl


pH : 7,36

pCO2 : 42

pO2 : 35

HCO3-: 23,7

BEecf : -1,7

So2c : 64 %


22/32

5/20/2014

working diagnose :

sepsis ec bronkopnemonia duplex (HAP) with

respiratory failure type 1

IO with lung TB duplex + oral candidiasis

moderate anemia normositik normokrom ecchronic disease

hiponatremia ec low intake


23/32

5/20/2014

therapy:

rest/ NGT diet MC TKTP/ sungkup NRM 10 l/i for 6 hours--> O2

5l/i

IVFD Nacl 0,9 % 6 hours/kolf

inj. meropenem 3x1 gram (iv) skin tes

cotrimoxazole 1x960 mg

fluconazole 1x150 mg

ambroxol syrup 3xcth II

paracetamol 3x500 mg

crossmatch

transfution PRC 1 unit untill >= 10 gr/dl

catheter urine --> fluid balance


24/32

5/20/2014

PLAN

exp.rontgen thorax

BTA I,II,III

blood culture sputum VCT


25/32

ASMAR, Male 65 yo,PETRICc : swolen at upper right stomach since 15 days ago


swolen at upper right stomach since 15 days ago, it has been feltsince 1 month ago and increase in this 2 weeks , sometimes

patient felt pain also,intermitent pain. patient felt full faster than usual while eating since 15 days ago

decrease of body weight (+) about 5 kg in the last1 month

decrease of apetite (+) since 1 month ago

fatigue has been felt since 2 weeks ago

history of black stool (-), bloody vomit (-)


26/32

26

- fever (-)

- nausea (-), vomit (-)-history of sleep disorder (-)- history of hepatitis (-)- history of drink alkohol (-)- history of hypertention and diabetes (-)- defecation and mixturition normally

family history illness:his mother suffered ca. mamae


27/32



BP: 120/80 mmHgHR: 100x/

RR: 20x/

T:370C

Eye : anemic (-)/(-), icteric (-)

neck : JVP 5-2 cmH2O


Lung: normochest,simetris,sonor,

vesikuler, rales (-/-), wh (-/-)

Heart: ictus unseen,ictus was palpable 1 finger medialLMCS RIC V,regular rhtym,gallop(-)


28/32

5/20/2014




spider nevi (-)kolateral (-)

extremity : RF +/+, RP -/-, edema -/, palmar

eritem (-)


29/32

LABOR

Hb : 12,7gr.dlHt : 40%leukosit : 6.600/mm3



30/32

5/20/2014

working diagnose :

Hepatoma


31/32

5/20/2014

therapy:

rest/ DH II

IVFD aminofusin hepar : triofusin 1:2 8 hour/kolf

curcuma 3x1

sistenol 3x1 tab


32/32

PLAN

.USG abdomen

. hepatitis marker

.

Documents

Duty Report 28 April 2014