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DUTY REPORT

29 NOVEMBER 2014
BY: Wan Adi Surya and Elita Riyu

Summary of
Data Base
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 for
HD. Since 2
days before
admisions,
pasien suffered
form weakness,
lossing of

Physical Examination
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 ()

Laboratory Findings
(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:54
HbsAg: Negatif
Anti HCV: Negatif

Cues and Clues


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

Problem List
1. SOB

Initial Diagnosis
1.1 Uremic lung
1.2 HC st.C fc.3

PDx
CXR photo
Blood Gas Artery
(BGA)
Electro
Cardiography
Cardiac marker

PTx
O2 2-4 lpm NC
Soft kidney diet
1900 kkal, protein
0,6-0,8g/kgBB/day
PO:
NaBic 3x500 mg
CaC03 3x100 mg

Pmo
Subjective, VS
Urine production

Continue HD as
scheduled

BP: 90/60 mmHg


HR: 88 bpm, reguler
RR: 24x/m
Lab findings:
Ur: 400,20 mg/dL
Cr: 29,3 mg/dL
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 as
scheduled

Subjective, VS,
Urine production

appetite,
nausea (+), but
no vomitting,
feeling of
fullness. Patient
is diagnosed
with HT since 3
years 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 jamujamuan 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 ward
PR 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

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

PO:
Omeprazole 2x20
mg
Amlodipin 1x12 mg

5.1 Related to CKD


5.1.1 Defisiensi Epo

Blood smear

Confirmed
diagnosis
Epo transfusion is
planned

Sujective, VS

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