January 18th , 2018

DUTY REPORT
MARTUNIS, 58 YO, MALE, MW 10
 Chief Complaint:
 Pain at the left waist since 2 weeks ago
 Present Illness History
 Pain at the waist since 2 weeks ago, appear and
disappears
 Nausea (+) since 2 weeks ago
 Vomit (+) since 2 weeks ago, contain stomach
contents, black (-)
 Patient was sent from Yarsi hospital pasaman
with kidney failure, and instructed to be
hemodialyzed
 Micturation: normal, blood (-)
 Defecation: normal
Past illness history
 History of hypertension denied

 History of diabetes denied

PHYSICAL EXAMINATION
 Consciousness level: CM

 BP : 120/80 mmHg

 HR : 90 x/minute

 RR : 19 x/minute

 T: 36,8 C
 Eye
 Anemic conjunctiva (-)
 Icteric sclera(-)
 Neck
 JVP 5-2 cmH20
 No lymph enlargement
Lung:
 Inspection: statically & dynamically symmetric sin=dextra
 Palpation: fremitus equal in both side
 Percussion: sonor on both lung
 Auscultation: vesicular, rales -/-, wheezing -/-

 Cor:
 Inspection: ictus is not seen.
 Palpation: ictus is palpated at 1 finger medial LMCS ICS V
 Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: ICS II
 Auscultation: regular, murmur (-)
 Abdomen:
 Inspection: no enlargement (-)
 Palpation: liver and spleen are not palpable
 Percussion: tympani
 Auscultation: bowel sound (+) N

 Extremities:
 Dry skin (+)
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema pretibia +/+
LABORATORY

Hb 11,3 gr/dl

Ht 31

WBC 13.340/Mm3

Platelet 413.000/Mm3

Ur/Cr 345 /16,5

Na/K/Cl 141/4,1/106
Total Protein 7,8
Alb/Glo 4,2/3,6
CHEST X-RAY
ECG
WORKING DIAGNOSE

 Acute on CKD
 UTI
THERAPY
 Rest/ MB diet protein 40 gr
 IVFD NaCl 0,9% 24 hrs/kolf

 Domperidon 3x10 mg
PLAN

 Hemodialysis