You are on page 1of 6

Duty Report Saturday, 23-11-2013 Physician In Charge: Jaga IA: dr. Vina, dr.

Arya, dr Yoseph (cardio) Jaga IB: dr. Saras, dr Ananto Jaga II : dr. Achmad Rifai Jaga III: dr.Nur samsu, Sp.PD-KGH

Summary Of Database: Tn sudjak / 53 yo/ w 26 Chief complaint: decreased of conciousness Patient suffered from decreased of concioussness since 2 day before admission, gradually onset, worsening 1 day before admission. Previously he admitted at Pandaan PHC because her condition getting worse, he reffered to RSSA. 1 month before, he often suffered from nausea and vomiting and admitted at PHC for 1 week and the complain was relieved. General weakness since 2 months ago, He also complain about cough with withis sputum and fever intermittenly since 1 week ago, shortness of breath (-) He complain about back pain about 2 years, intermittenly. Passing urine and passing stool normal as usual. History of diabetes mellitus since 9 years ago, not routinely control didnt consume medicine. History of hypertension since 7 years ago, also not took drug No history of shortness of breath, sleep with one pillow, never wake up in the night because shortness of breath Social history: patient hadbeen retired from prhad 4 childern, often consume traditional potion one times per week

Physical Examination: GA: Look modrately ill; GCS 446 BP : 120/100 mmHg PR: 112 bpm RR:24tpm Tax:37.1 Head : an +/+ ict -/JVP : R+3 cm H2O (30) Chest : Cor : Ictus visible & palpable at ICS V 1cm lat MCL S LHM: ictus , heart waist RHM: SL D S1 S2 single murmur (-) Pulmo : Symmetric; Stem fremitus D=S, ves/ves rhonki -/- and wheezing -/Abdomen : flat, soefl, BS + normal, LS 8 cm, traube space thympany, shifting dullness

Extremity : Warm acral, edema -/Urine Output Production: 500 cc/4 hour

Laboratory Findings Leukocyte Hb MCV MCH Hematocrite Thrombocyte RBS SGOT SGPT Ureum Creatinine eGFR Albumin Na K Cl Diff count FH PPT K INR APTT Kontrol

: 3670/mm3 : 5.90 g/dl : 80.30 fL : 26.50 pg : 17.90 % : 227 10/uL : 181 mg/dl : 17 U/L : 13 U/L : 371.50 mg/dl : 31.45 mg/dl : 2.3 : : 137 mmol/L : 5.77 mmol/L : 105 mmol/L : 0.1/0.1/85.2/7.7/6.8 : : 13.4 : 11.5 : 1.19 : 25.9 : 27.0

BGA: O2 10 liter supplemental pH :7.14 pCO2 :22.1 mmHg pO2 :238.9 mmHg true O2 : HCO3 :10.5 mmol/L BE : -21.6mmol/L Sat O2 : 99.3% Conclusion: acidosis metabolic partially compensated with

CXR AP position, Asymmetric, enough inspiration, enough KV Trachea in the middle, bone n soft tissue normal Hemidifragma D/s dome shape Costophrenicocostalis angle D/S : sharp

Pulmo : BVP normal Cor : site N, size 58% Conclusion: cardiomegaly ECG: Sinus tachycardia with heart rate 100 bpm Frontal Axis : Normal Horizontal Axis : Normal PR Interval : 0.12 QRS complex : 0.06 QT interval : 0.44 QT corrected: S V2 + R V6 >= 35 LVH Conclusion: sinus tachycardia

Cue & clue Male 53 yo DOC Gradually onset General weakness Nausea Vomiting Cough for 1 week Fever for 1 week DM for 9 years HT for 7 years Px: GCS 225 446 Anemia (+) BP:220/100 PR: 112 RR: 24 Lab: Ur/Cr: 371.50/31.45 eGFR: 2.34 BGA: acidosis metabolic partially compensated

PL IDx 1. Decreased 1.1 uremic of encephalopath conciousness y 1.2 septic condition 1.3 hypertension emergency

PDx Sputum culture and sensitivity test

PTx O2 8-10 lpm HD cito

PMo Subj Vital sign Urine output production Pedu: progonosed, condition

Ro Thorax: cardiomegaly Male 53 yo General weakness Nausea Vomiting DM for 9 years HT for 7 years Px: GCS 225 446 Anemia (+) BP:220/100 PR: 112 RR: 24 Lab: Ur/Cr: 371.50/31.45 eGFR: 2.34 BGA: acidosis metabolic partially compensated Ro Thorax: cardiomegaly Male 53 yo DM for 9 years HT for 7 years Px: GCS 225 446 Anemia (+) BP:220/100 PR: 112 RR: 24 Lab: RBS 181 Ur/Cr: 371.50/31.45 eGFR: 2.34 BGA: acidosis metabolic partially

2. CKD stage 2.1 DM 5 newly cardiomyopath diagnosed y 2.2 Hypertension nephrosclerosi s 2.3 GNC

Abdominal USG Biopsy ginjal

HD cito

VS Subj. Urine output production Pedu: Prepare for renal replacement therapy

3.DM type 2 poorly controlled

FBG, 2hPPBG HbA1C

Plan for insulin

Subj,VS, urine outputprodu ction Tarhet organ damage Pedu: compliance to the medication

compensated Ro Thorax: cardiomegaly Male 53 yo DM for 9 years HT for 7 years Px: GCS 225 446 Anemia (+) BP:220/100 PR: 112 RR: 24 Ictus 1 cm lat ICS V MCL S Ro Thorax: cardiomegaly Male/53 yo SOB (-) Ortopneu (-) PND (-) BP 220/100 JVP R+3 cm H2O Ictus 1 cm lat ICS V MCL S ECG: sinus tachycardia with LVH CXR: cardiomegaly Male 53 yo Nausea Vomiting DM for 9 years HT for 7 years BGA: acidosis metabolic partially compensated Male/53 yo Pale conjunctiva +/+ 4. hypertension emergency 4.1 renopharenchy mal hypertension 4.2 hypertension nephrosclerosi s Lipid profile, funduscopy Drip nicardipin 5-15 miligram/ho ur untill MAP decreased 25% first MAP Subj, VS Target organ damage P Ed: low salt diet

5. HF stage B

5.1 DM cardiomyopath y 5.2 HHD 5.3 uremic cardiomyopath y

Echocardiogr aphy

Control blood pressure after emergency relieved

Subj, VS

6. Metabolic ascidosis

6.1 dt CKD st V

HD cito Nabic 3x500mg

Subj,VS, BGA

7. anemoa NN

7.1 dt chronic disease

Transfusion 1 pack PRC durante HD

Subj VS Overload

Hb: 5.90 MCV: 80.30 MCH 25.30 Male/53 yo Low back pain Intermittenly Since 2 years Not reffered

8. back pain

8.1 mechanical Lumbosacral 8.2 plain photo spondilosys lumbalis 8.3 HNP

Paracetamol 3X500 mg when needed

sign Complete blood count Subjective VS