Duty Report

Saturday, October 11th 2014

Coass :
Erdo Puncak Sidarta
Adinda Amaliadani
Supervisor :
dr. Sri Sunarti, Sp.PD
Mrs. Misri/ 39Yo/ w 28
Chief complaint : Nausea and vomiting
Patient complains about nausea followed by vomiting since 4
months ago, worsen in the last 2 months. She vomits 4-5 times /day,
usually after she eats. The vomit contains residual food and fluid. Because
of it, her appetite is decreasing and she feels weak. She can still be doing
daily activities but it is limited, because she gets tired easily. She went to
a doctor and got 3 medications, one of them is Sipolan. After she took
those medications, symptoms of nausea and vomiting is gone but she felt
even weaker. Because of that she stopped consuming the medication.
Patient also complains about cough since 1 month ago. The cough
started after she consumes Captopril, but cough still presents even
though she stopped consuming Captopril. She cant sleep at night
because her throat felt itchy and she always coughs. She tried to relieve
the symptoms with hot drinks.
Patient also complains that her abdomen is getting bigger and felt
painful when shes in sitting position. She felt pain since before treatment
at primary health care, 4 months ago. She has done USG examination at
RSSA and said to have fluid inside her abdomen.
4 months ago she was treated at primary health care for 4 days
because of nausea and vomiting. She was given medication such as
Promag and the symptoms relieved so she went home. She also
complains about recurrent headache since a month ago, relieved by
painkiller drugs such as Bodrex and Poldanmig, or when she rests but then
it appears again. Patient also likes to drink traditional potion with
ingredients like kunyit and kayu-kayuan.
She denied that she has hypertension or Diabetes Mellitus, but a
week ago when she checked to a doctor her blood pressure 200/130
mmHg. She doesnt smoke nor consumes alcohol. Her passing stool and
passing urine is normal.

History of pass illness : Familly history :

Her mother had hypertension, and there was no story of diabetes
She is married, and has 2 children, menstruation cycle was normal

Physical Examination
BP=
PR= 80 bpm
RR =22 tpm
Ax. Temp.=
160/100mmHg
37,20C
General App.: look moderatelly
GCS : 456
ill, looked underweight, looked
pale
Head
Anemic conjunctiva Icteric sclerae
Lnn.
(+)
(-)
Enlargement (-)
0,
Neck
JVP : R+ 2 cm H2O; 30
Thorax
Cor
Ictus invisible, palpable at ICS V MCL S
RHM SL
LHM ictus
S1, S2 single, no murmur
Pulmo

Abdomen
Extremities
LAB

Symmetric; SF D=S; S| S
V | V Rh
Wh - | S| S
V|V
-| -| S| S
V |V
-|-|-

-| -

Rounded,slight distended, Epigastrial tenderness,

meteorismus (+) BS (N) troube space dullness, liver
span 10 cm, shifting dullness (+),
Edema (-),parese (-), warm acral (+)

5850

NORMAL
VALUE
3,500-

Sodium

125

6.90

10,000/L
11.0-16.5

Potassi

6,11

MCV
MCH

85,50
27,70

g/dl
80-97 m3
26.5-33.5

um
Chloride

3.5-5.0
mmol/L

106

98-106
mmol/L

PCV

21,30

m3
35-50%

RBS

93

Thrombocyte

153.000

150,000-

Ureum

277,1

>200
mg/dL
10-50
mg/dL

Leucocyte
Hemoglobine

RESULT

390,000/l

LAB

RESULT

NORMAL
VALUE
136-145
mmol/l

Diff count
Eos/Ba/Neu/Ly/

1,5/0,2/68,
9/23,4/6,0

0-4/0-1/51-

Creatini

67/25-33/2-5

ne

16,82

0.7-1.5
mg/dL

Mo
eGFR

2,53
mL/min/1,73m2

CXR
AP position, asymmetric, less KV, less inspiration
Soft tissue normal, Bone normal
Trachea in the middle
Hemi diaphragm D and S dome shape
Phrenicocostalis angle Right and left sharp
Pulmoright and left normal
Cor : site N, size CTR 50%, heart waist normal
Conclusion : normal chest x ray
ECG

Sinus rhythm, heart rate 72 beats/minute

Frontal axis
: normal
Horizontal axis
: normal
PR interval
: 0,16 second
QRS interval
: 0,10 second
QT interval
: 0,42 second
Tall T
Conclusion : sinus rhythm with heart rate 72 beat per minute
With suggestion hyperpotassemia

CUE & CLUE

PL
Female/39Yo/W.2 1.Dyspep
8
sia
Anamnesis :
Syndr
Nausea vomiting
ome
for 4 months.
Vomits 4-5x
/day, after she
eats. The vomit

Idx

PDx

PTx

Pmo
Subjective
VS
Dehydration
signs

contains residual
food and fluid.
Lab :
Ureum: 277,1
mg/dl
Catinin:16,82
mg/dl
eGFR 2,35
ml/min/1,73m2
Hb:6.90 gr/dl
Female/39Yo/W.2
8
Anamnesis :
Weakness
Nausea vomiting
History of
hypertension
PE :
BP: 160/100
mmHg
PR: 80 bpm
RR:22 tpm
Tax :37,2
Conjunctiva
anemia
Lab :
Ureum: 277,1
mg/dl
Catinin:16,82
mg/dl
eGFR 2,35
ml/min/1,73m2
Hb:6.90 gr/dl
Female/39Yo/W.2
8
Anamnesis :
General
Weakness
Decrease of
appetite
PE :
BP: 160/100
mmHg
PR: 80 bpm
RR:22 tpm
Tax :37,2
Conjunctiva
anemia
Lab :
Ureum: 277,1
mg/dl
Creatinin:16,82
mg/dl

2. CKD
stage 5
newly
diagnose
d

2.1
Hypertensio
n
nephroscler
osis)
2.2 NSAID
nephropath
y

USG
abdomen

Renal diet 1700

kcal/day, low salt 2
gr/day, low protein 11.2 gr/bw/day
Inj. Metoclopramide 3
x 10 mg
Peroral :
Omeprazole 2 x 20 mg

Subjective
VS
Urine output
Ureum
Creatinin
eGFR

Plan for elective

hemodyalisis

3.
General
weaknes
s

3.1
moderate
hyperpotas
semia
3.2 due to
ckd st 5

Bed rest
Renal diet 1700
kcal/day, low salt 2
gr/day, low protein
0,6-0,8 gr/bw/day, low
potassium
Potassium correction
- Ca gluconas inj
1Amp iv
- Inj d40 % 2 fl
- Inj actrapid 10
iu iv

Subjective
VS
SE
post
correction

eGFR 2,35
ml/min/1,73m2
Hb:6.90 gr/dl
ECG :
Sinus rhythm
with heart rate
72 bpm
With suggestion
hyperpotassemi
a
(tall T)
Female/39
Yo/w.28
Anamnesis:
History of
hypertension
History of family
with high blood
pressure
PE:
BP:
160/100mmHg
Female/39
Yo/w.28
Dyspnea in
moderate
activity
Conjunctiva
anemia
Lab :
Hb:6.90 gr/dl
Ureum: 277,1
mg/dl
Creatinin:16,82
mg/dl
eGFR 2,35 ml/
min/ 1,73 m2

4.
Hyperten
sion st II

Female/39
Yo/w.28
General
weakness
Conjunctiva
anemia
Lab :
Hb:6.90 gr/dl
MCV: 85,5
MCH: 27,7
Ureum: 277,1
mg/dl
Creatinin:16,82
mg/dl
eGFR 2,35 ml/

6.
anemia
related
CKD

5. HF
stage C
FC II

4.1
secondary
HT
4.1.1
renovascula
r HT
4.1.2
renoparenc
himal HT
4.2 primary
HT
5.1 HHD
5.2 CAD
5.3 uremic
cardiomyop
athy
5.4 Anemia
herat
disease

fundusco
py

Amlodipine 1x10 mg
Clonidine 3x0,15 mg

Subjective
Blood
pressure

Echocardi
ogram

Furosemide inj 40mg0-0 iv

Subjective
VS
Urine
production
Body weight

6.1
Deficiency
of
erythropoie
tin
6.2
Deficiency
of Fe
6.3 Low
protein
intake
6.4
Increased
red cells
destruction

Serum
iron
TIBC
Ferritin
Blood
smear

Treat
underlying
disease
Transfusion 1 pack
PRC durate HD until
Hb 7 gr/dl

Subjective
VS
CBC
Urin output

min/ 1,73 m2