EMERGENCY UNIT

DUTY REPORT
23RD JANUARY 2015
Resident on duty: dr. Evan
Coass on duty: Zikril & Aris

RECAPITULATION PATIENT
Floor

Patient (8)

3
4

Mrs. S, 45 years old, CKD Stage V, DM Type 2

Mr. M, 52 years old, Fever on SIDA
Tn. L, 47 years old, dyspeptic syndrome, DM Type 2

Mrs.N, 32 years old, Typhiod fever

PATIENTS IDENTITY
Name
:
Sex
:
Medical Record
Age
:
Religion
:
Marital Status
Work
:
Address
:

Mrs. S
Female
: 800133
45 years old
Moslem
: Married
housewife
South Kalimantan

ANAMNESIS
Autoanamnesis on 23 rd 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 (-)

FAMILY ILLNESS
Dad patients suffering from type 2 diabetes mellitus
Ren,heart, and lung illnes (-)

HABITS AND LIFESTYLE

There were no history of smoking, alcoholic drinking, taking
drugs.

PHYSICAL EXAMINATION
VITAL SIGNS
General State
Consciousness
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Body Weight
Body Height
BMI

:
:
:

Moderate Sickness
Compos Mentis
: 210/90 mmHg
68 x/minute
: 24 x/minute
: 36.3oC
: 62 kg
: 160 cm
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
LABORATORIUM (19-01-2015)
RESULT

NORMAL RANGE

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

routine hematology :

RESULT

NORMAL RANGE

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

Clinical Chemistry :

JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

Warna

Keruh*

Kuning

Kejernihan

Keruh*

Jernih

5,5

4,6-8,0

1,015

1,010-1,030

Protein

Positif 3*

Negatif

Glukosa

Negatif

Negatif

Bilirubin

Negatif

Negatif

Urinalisis

pH
Beratt Jenis

JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

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

Bakteri +/positif 1 *

Negatif

Urinalisis

Lain lain

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.
2.
3.
4.

CKD stage V
Diabetes Melitus Type 2
hypertensive urgency
Hypoalbuminemia

ASSESSMENT
1. 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

ASSESSMENT
2. 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