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