1( Dr.

Bobi)
Duty Report
Saturday, Nopember 5 th, 2015
Moderator :
Physician In
I
II CVCU
II HCU
II UGD
Chief jaga
III

Charge:
: dr. Bobby, dr. Alul, dr. Fadillah, dr.Intan
: dr.Kathy
: dr.Soemarnam
: dr. Yanti, dr. Vina
: dr,Ade
: dr. Dewi Sp.PD

Summary Of Database:
Ny.Puji Utami/52 Y.O/W 22A
Patient felt of general weakness since 5 days recently. Yesterday she felt hard for standing
up. She suffered from general weakness and since a month before admission. She did not has
enough power to do her daily activities.
The right side of her body is worse than the left side. it never happen before.
Patient felt shortness of breath since 5 days ago. Actually, she began felt shortness of breath since
3 months ago when doing hard activities, but it get worsen recent 5 days after she underwent
routinelly HD lately so that she couldnt do mild activity, even only walk for 1-2 meters. She used to
sleep with 3-4 pillows, she often woke up in the night because of shortness of breath.
She had been diagnosed as kidney disease since 2 month ago and undergo hemodialysis Her last
HD was 2 days before admission.
The patient knew that she had hypertension and diabetes mellitus since 10 years ago, but
she never did general check up to doctor to control her blood pressure routinely. Her blood pressure
used to reach 180/... mmHg. She didnt know precisely about his blood glucose level. She only used
captopril or glibenclamide to control hypertension and blood glucose.
She used to a consume traditional potion.She routine consumed herbal remedies since 3
years ago. She took herbal remedies whenever she felt joint pain
ast Medical History:
Family Medical History:
Her mother have DM and HT.
Social History:
She is a housewife, has 1 child, no smoking habit or alcohol consumption. She consumed traditional
potion everyday for a month 10 years ago

Physical Examination
PR= 110 bpm
RR =28 tpm
Ax. Temp.= 36.5 0C
regular
General App.: looked moderately ill,
GCS : 456
attached to O2 NRBM 10 lpm
Looked normoweight
Head
Anemic conjunctiva
Icteric sclerae (-)
Lnn. Enlargement
(+)
(-)
Neck
JVP : R + 4 cm H2O; 300
Thorax
Cor
Ictus invisible, palpable at 1 cm lateral sixth ICS,
MCL S
RHM PS line D
LHM ictus
S1, S2 single, no murmur
Pulmo
Symmetric; SF D=S; S| S
V|V
Rh -| Wh - | S| S
V|V
-|-| S| S
V |V
-| -|BP= 130/80 mmHg

Abdomen
Extremities

Flat, BS (N), liver span 8 cm, traube space tympany, flank pain
D/S -, suprapubic pain -,
soft, epigastric tenderness (-)
Edema (-),

LABORATORY FINDINGS
LAB

VALUE

NORMAL

LAB

VALUE

NORMAL

Hemoglobin
MCV
MCH
Leukocyte

4, 40
71,20
21,20
10750

RBS
Ureum

304
111,30

< 200 mg/dl

10-50 mg/dL

Creatinine

6,24

0,7-1,5 mg/dL

Eo/Bas/Neu/
Limf/Mon

1,1/0.1/76.7/
11.017,8/4,4

11,0-16,5 g/dl
80-96 f
26,5-33,5 pg
3.50010.000/L
0-4/0-1/5167/25-33/2-5

PCV
Trombocyte

35.7
248,000

SGOT
SGPT

35
34

35-50%
150.000390.000/L
0-32 U/L
0-32 U/L

eGFR

Ml/min/1.73m2

Natrium

132

Kalium
Chlorida

3,76
103

136-145
mmol/L
3,5-5,0 mmol/L
98-106 mmol/L

ECG:
Sinus rhythim, HR : 110 bpm
PR interval
: 0,12
QRS complex
: 0,08
QT interval
: 0,36
Frontal Axis
: clockwise rotation
Horisontal Axis
:N
Conclusion : sinus tachycardia, HR 110 bpm,

CUE&CLUE
Female/52
years
old/w.22
General
weakness,co
uldn wake up
and walk,
History of HT,
DM
History
routine HD
Dextra
Hemipharesis
MO 3 5
3 5
JVP: R+3

PL
1.General
weakness
and+dextra
hemipharesis

IDx
1.1 Susp CVA
trombosis

PDx

PTx
Consult to Neurology
departement

PMo
Monitor
Motoric
response

cmH2O,
Hb 4,40
Ureum:
111,30
Creatinin:
6,24
eGFR:
Female/52
years
old/w.22
Shortness of
breath
PND,
History of HT,
DM
History
routine HD
JVP: R+3
cmH2O,
Hb 4,40
Ureum:
111,30
Creatinin:
6,24
eGFR: 13

2.SOB

Female/52
years
old/w.22
Shortness of
breath
PND,
History of HT,
DM
History
routine HD
Anemic
conujunctiva
+JVP: R+4
cmH2O,
Hb 4,4
Ureum:
111,30
Creatinin:
6,24
eGFR: 13

3. Chronic
kidney disease
stage 5 on
routine HD

Female/52
years
old/w.22
Hb: 4,40
MCV: 71,20
MCH: 21,20

4.Anemia
normochrome
normocyter

Female/52
Yo/w.22

5. Diabetes
mellitus type 2

1.1 Uremic
lung
1.2 HF st C fc
IV
1.3 Anemia
gravis

BGA

3.1

Hypertensi
ve
nephropat
hy
3.2 Diabetic
nephropat
hy

4.1 Defiensi
EPO
4.2 Low
protein
intake

Bed rest semifowler

position
O2 4 L/minute nasal
canul
Fluid balance minus
500 mL/day
Kidney diet, low salt
<2 g/day, protein 40
g/day,

Monitoring:
Subjective
Vital signs
Urine output

Routinelly HD
Furosemid inj 40-40- 0
iv

Monitoring:
Subjective
Vital signs
Urine output
Ur/Cr per 3
days

Education:
Reduce fluid
intake,
protein, salt,
kalium intake

Education:
Reduce fluid
intake,
protein, salt,
kalium intake

Serum iron
TIBC
ferritin

Treat underlying
condition
PRC transfusion 1 pack
durante HD

Monitoring:
Subjective
Vital signs

FBG/2HPPB

DM diit 1700
kkal/day,less salt <2

Monitoring:
Subjective

History of
diabetes
mellitus
since 20
years ago
Routine used
insuline
PE:
BP :130/90
mmHg
PR: 110 bpm
RR: 28 tpm
Tax: 36.70 C
RBS: 304
mg/dl

unroutinelly
control

Female/52
years
Shortness of
breath
PND,
History of HT,
DM
History
routine HD
JVP: R+3
cmH2O
Ureum:
111,30
Creatinin:
6,24
eGFR: 13

6.Heart failure
stage C
functional class
IV

6.1 Uremic
cardiomyo
pathy
6.2 Diabetic
cardiomyo
pathy
6.3
Hypertensi
ve
cardiomyo
pathy

Echocardio
graphy

gr/day
Protein 40 gr/day
Lantus 0-10 IU SC

Vital sign
HbA1c

Control hypertension
Furosemid 40-40- 0 mg
iv
Amlodipin 1x10 mg
Irbesartan 3x500 mg

Monitoring:
Subjective
Vital signs
Urine output,
fluid balance
Education:
Reduce fluid
intake