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  1. 1. Resident on duty : dr. Wahyu Coass on duty : Monica, Kara Supervisor : dr Soroy Lardo SpPD FINASIM DUTY REPORT FEBRUARY 5TH 2014 CKD AND HHD DEPARTMENT OF INTERNAL MEDICINE INDONESIA ARMY CENTRAL HOSPITAL GATOT SOEBROTO
  2. 2. PATIENT RECAPITULATION Ward : 2 new patients 6th floor : 1 new patient Mr. JL, 42 yo, Dx: observation on febris day 5 ec DHF dd/ Typhoid fever. 5th floor : 1 new patient Mrs. SS, 48 yo, Dx: CKD stage V with anemia normocytic normochrom and acidosis metabolic; hyperkalemia; CHF fc II ec HHD 4th floor : - 3rd floor : -
  3. 3. PATIENTS IDENTITY Name : Mrs. SS Sex : Female Age : 48 years old Job : Housewife Religion : Moslem Marital Status : Married Address : Perumahan Graha Prima Blok Mawar 27 No 18 Bekasi
  4. 4. ANAMNESIS Autoanamnesis on February 5th 2014 at 10.30 PM Chief Complain: General weakness since Monday Additional Complain: Dry cough
  5. 5. CURRENT ILLNESS Patient was admitted to ward with general weakness since Monday. Her complain became worsen day by day and she couldnt continue her daily activities. She also complained of having dry cough without blood since Monday. She denied any fever, shivering, night sweat and unexplained weight loss. There was history of dyspnea 2 days ago, DOE (-), OP (-), PND (-), chest pain (-), excessive sweating (-), nausea (-) and vomiting (-). There was also history of swollen legs 4 days ago. There were no complains of micturition and defecation, the quantity are within normal limit. Fluid balance of input and output was equal.
  6. 6. CURRENT ILLNESS Patient was diagnosed with Chronic Kidney Disease stage V. She was suggested to have hemodialysis but she refused because she thought that she is in good condition. She suffered hypertension for 4 years and take routine medications with Amlodipine 1 x 10 mg and Valsartan 1 x 160 mg.
  7. 7. Past Medical History Diabetes (-) Cardiac disease (-) Allergy (-) No family member with the same symptom Hypertension (-) Diabetes (-) Cardiac disease (-) Allergy (-) Family Medical History
  8. 8. PHYSICAL EXAMINATION VITAL SIGNS Consciousness :Compos Mentis General State : Moderate Sickness Blood Pressure :130/100 mmHg Heart Rate : 112 x/minute, regular Respiratory Rate : 22 x/minute, regular Temperature : 37,9o C Body Weight : 42 kg Body Height : 150 cm BMI : 18.6 (normoweight)
  9. 9. PHYSICAL EXAMINATION General Examination Head : Normocephal Eye : anemic conjunctiva (+/+), icteric sclera (-/-) Ears : normotia, discharge (-) Nose : septum deviation (-), discharge (-) Mouth : pale lips, normal tongue, hyperemic pharynx (-), T1- T1 Neck : lymph nodes enlargement (-), JVP 5-2 cmH2O
  10. 10. Thorax : normothorax, symmetric, intercostal retraction (-) Cor : Inspection : ictus cordis was not visible Palpation : ictus cordis palpated Percussion : right cardiac margin at 5th ICS parasternal dextra line, upper cardiac margin at 3rd ICS parasternal sinistra line and left cardiac margin at 5th ICS anterior axillary line. Auscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-) Pulmo : vesicular breathing sounds, rhonchi (-/-), wheezing (-/-) Abdomen : flat, soft, tympani, no enlargement of liver & lien, bowel sound normal, tenderness (-) Extremities : warm, pitting edema (-), cyanosis (-) CRT < 2 seconds
  11. 11. DIAGNOSTIC PLANS RESULT NORMAL RANGE Hb 6.8 13 - 18 g/dl Ht 20 40 52 % Erythrocyte 2.3 4.3 - 6.0 mil /ul Leukocyte 6800 4800 - 10800/ul Thrombocyte 183000 150000 - 400000/ul MCV 87 80 96 fL MCH 30 27 - 32 pg MCHC 34 32 36 g/dL LABORATORY TESTS (Feb 5th 2014, 08.50 AM)
  12. 12. RESULT NORMAL RANGE Ureum 232 20-50/ mg/dL Creatinine 3.8 0.5-1.5 mg/dL Random blood glucose 107