Duty report

January 18th, 2018

Rico Yosandra, Male, 43yo,

Chiefcomplain
Decrease of conscioussness since 2 days
ago
 Present illness history
◦ Decrease of conscioussness since 2 days ago. Slowly
happened and looks sleepy.
◦ breathlessness increased since 3 days ago. actually felt
since 2 weeks ago. Not affected by activity, weather,
and food. Sleeping with elevated pillows is denied.
◦ Coughing since 1 week ago, sputum (+)
◦ Fever since 1 week ago, not high, not chill.
◦ History of swollen both of the leg, intermittent
◦ Nausea accompanied by vomiting since 2 weeks ago
◦ Urination volume decrease.
◦ Hystory of hypertension (+_
◦ Patient reffered to payakumbuh to get hemodialisa

12/03/2018
Physical Examination
 level of consciousness : CMC

 BP : 160 / 90 mmHg

 HR : 96 x/minute

 RR : 20 x/minute

 T: 36,8 oC
 Eye
◦ Conjunctiva are anemic +/+
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation: Bronchovesicular, Rh +/+ , Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medial LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur (-)
 Abdomen:
◦Inspection: Enlargement (-)
◦Palpation: liver and spleen not palpable
◦Percussion: tympani
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema +/+
Laboratory
Examination Result
Hb 6,0 g / dl
Leukosit 8.930 / mm3
Trombosit 196.000 / mm3
Hematokrit 16 %
Ur / Cr 346 / 27,5
Na / K / Ca 98 /5,8 / 63
Ph 7,4
Pc02 15.5
Po2 155,8
Hco3- 9,7
Beecf -15,3
s02 99,1

12/03/2018
12/03/2018
Working Diagnose
 Decrease of consciousness cb uremic
enchefalopathy
 CKD stage V ec hypertensive
nephropathy
 Moderate Anemia normocytic
normochrom cb chronic disease
 Bronchopneumonia dupleks (CAP)
 Hyponatremia cb renal loss
 DD/ Decrease of consciousness cb
hyponatremia
Therapy
 Rest/ low salt II low protei 40 gr via NGT/ 02 2 L / I
 IVFD nacl 3% 12 hr/kolf (2 kolf)
 IVFD easprimmer 500 cc / 24 hours
 Bicnat 3 x 500 mg
 Folic acid 1 x 5 mg
 Amlodipine 1 x 10 mg
 Candersartan 1 x 16 mg
 Paracetamol 3 x 500 mg
 N. Acetil sistein 3 x 200 mg
 Ceftriaxone 2x1 gr
 Fluid balance