Duty report

January 29, 2018

Erita , female, 49 yo, hcu A

Chiefcomplain
Breathlessness since 1 days ago
 Present illness history
◦ Breathlessness since 1 days ago. Influenced by activity,
not influenced by activity, weather and food. Sleep
with elevated pillow (-)
◦ Naussea and vomit (-)
◦ Paleness since 1 month ago
◦ Fever since 2 days ago
◦ Cough since 2 days ago with sputum
◦ Urination was decrease
◦ Defecation was normal
◦ Pasient had been know suffer kidney disease and get
routine HD 4 times

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

 BP : 170 / 90 mmHg

 HR : 92 x/minute

 RR : 27 x/minute

 T: 36,9 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 lateral LMCS RIC VI
◦ Percussion:
 Left border: 1 finger lateral LMCS RIC VI
 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 7,3 g/dl
Leukosit 7740 / mm3
Trombosit 169.000 / mm3
Ur / Cr 77 /5,7
GDS 177
Na / K / Cl 135/3,8/103
Hematokrit 24%
Ph 7,41
Pco2 42,5
Po2 36,2
Hco3- 27,3
Beecf -12,9
So2 76,6

12/03/2018
Working Diagnose
 Bronchopneumonia dupleks (HCAP) wit
respiratory failure type 1
 CKD stg V on HD
 Mild anemia normocytic normochrom cb
chronic disease
 Type 2 DM controlled.
 CHF fc II LVH RVH sinus rhythm cb
HHD
Therapy
 rest / protein 50 gr low salt II / NRM 02 10 L/i
 IVFD easprimmer 500cc/24 hr
 Paracetamol 3x500mg
 N.acetil sistein 3x200 mg
 Nebu flumucyl/8 hr
 Ceftazidime 2x 1 gr
 Levofloxacin 1x 500 mg
 Bicnat 3x 500 mg
 Amlodipin 1x 10 mg
 Candesartan 1x16 mg
 Fluid balance
12/03/2018