DUTY REPORT

Saturday, 19 December 2015

PHYSICIAN INCHARGE
IA : dr. Jaja, dr. Yuni, dr. Fadhila
IB HCu : dr. Somarnam
IB CVCU : dr. GErry
IB ER : dr. Awan, dr. Nina
Chief : dr. Herwindo
Consultant : dr. Bogi, SpPD-KGEH

Summary of Data base

Mrs. Subari/70 yo/W.26
Chief Complaint: Decrease of consciousness
Patient was referred to RSSA from private hospital because suffered decrease of
consciousness few hour before admission. Patient look very weakness and cannot answer question
with correct answer. Patient was undergoing hemodialise last night because kidney disorder.
Ten days before admission patient often lying down and decrease of his activity. Patient didn’t tell to
his family his real condition. He always said no problem if his family ask him. His appetite also
decrease, patient
He had hypertension, his daughter didn’t know when he first was diagnosed hypertension and didn’t
consume drugs routinely. He only went to doctor if he suffered headache and vertigo. His highest
blood pressure was 180/…. He never control his blood pressure routinely.
History of diabetes mellitus didn’t known.
Past Medical History & Medication: -

Social history: Patient work as farmer, married, have 2 children, never consume traditional potion,
he is a smoker with amount 2 bars/day

Family history: No one in his family has the same symptoms and/or disease like this.

Physical Examination

GCS 322 General Appearance : look severity ill

BP 150/90 mmHg PR 56 tpm, regular RR 20 tpm, Tax 36,4 0 C
(ward) (tachycardi)
Looked underweight
Head Anemic (-), Icteric (-), pupil isokorq
Neck JVP R + 0 cm H2O 300
Thorax Cor Ictus invisible, palpable at 2 cm ICS 5 MCL RHM – sternal dextra LHR –ictus
cordis
S1 – S2 reguler, murmur -

1
 Lung Stem fremitus SS v v Rh - - Wh - -
D=S
SS v v - - - -

SS v v - - - -

Abdomen Soefl, epigastric pain (-),bowel sound normal, liver span 8 cm, traube space
is tymphanic, shifting dullness(-)
Extremities Leg edema (-),dry skin (-)

Laboratory Finding

Laboratory Result Normal Unit

Value

Hb 9.4  9.3 11,4-15,1 g/dL

Leucocyte 9.300 11.000 4.700-11.300 /µL

Hematocrit 28.2 38-42 %

Thrombocyte 176.000 155.000 142.000- /µL

420.000

MCV 91.20 80-93 fL

MCH 29,80 27-31 pg

MCHC 32,70 32-36 g/dL

Differential count - 0-4/0-1/51- %

67/25-33/2-
5

SGOT 31 0-32 U/L

SGPT 9 0-32 U/L

RBS 110 <200 mg/dL

Ureum 78 32 16,6-48,5 mg/dL

Creatinine 3.06 2.03 <1,2 mg/dL

Natrium 138.9 133 136-145 mmol/L

Kalium 4.57 4.70 3,5-5,0 mmol/L

2
Chloride 106 109 98-106 mmol/L

Osmolaritas 269 280-295 Mmol/L

PPT 11,6 27.4-28.6 second

INR 1,6 0,8 – 1,3

APTT 23,4 second

Albumin 3,28 3.5-5.5 g/dL

Calsium 4.1 7.6-11.0 Mg/dL

Phospor 13.8 2,7-4.5 Mg/dL

HbSAG Non reactive

BGA

Value O2 : NRBM 8 L/m suplementation normal

pH 7.46 7.35 - 7.45
pCO2 24.2 35 - 45 mmHg
pO2 71.0 80 - 100 mmHg
HCO3 17.5 21 - 28 mmol/L
Base exess -6.5 (-3) – (+3)
Saturated O2 91% > 95%
Hb 6,7 g/dL
Conclusion Normal BGA in Anemic patient

Urinalisis
Lab Value Lab Value

Colour Yellow 10 x

SG 1015 Epithelia +

PH 6.0 Cylinder -

Leucocyte +1 Hyaline -

Nitrite Negative Granular -

Protein +2

Glucose negative

Erythrocyte 2+ 40 x

3
 Eritrosit 10.5/hpf dismorfic

Keton urine trace Leukocyte 4-10/hpf

Urobilinogen - Crystal -

Bilirubin - Bacteria + 46366x103

ECG:

 Sinus rhythm, Heart rate 56 bpm

 Frontal Axis : Normal
 Horizontal Axis : Normal
 PR interval : 0,16”
 QRS complex : 0,04”
 QT interval : 0,40”
Conclusion : Sinus tachycardia with HR 56 bpm

C X R:
AP position, assymetric, enough inspiration, enough KV, bone and soft tissue normal, trachea in the
middle, diaphragma dextra dome shape, diaphragma sinistra covered by cardiac shadow, sinus
costophrenicus dextra and sinistra sharp, cor site normal, shape normal size CTR 56%

Conclusion : cardiomegaly

Abdominal USG:
- Chronic parenchimatous renal disease bilateral
- BPH grade II
Ct Scan:
- Verry large area Subdural hemmorage (fronto-temporo-parietal) sinistra with tight 2,2cm
and midline shift to the right
- Cerebri oedema

4
Cue Clue PL I.Dx P.Dx P.Th/ P.Mo
Male 70 yo: 1. DOC 1.1 subdural Bed rest head -VS
Ax: hemorage up 30’ -Subjective
Decrease of Consult to
consciousness since few neurologic
hour before admission, surgery
was performed departement
hemodialise last night

PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm

CT Scan:
-Verry large area
Subdural hemmorage
(fronto-temporo-
parietal) sinistra with
tight 2,2cm and midline
shift to the right
-Cerebri oedema
Male 70 yo: 2. CKD 2.1 Ht Fluid diet 6x200cc VS
Ax stage 3 Nephrosclerosis Equal fluid Subjective
Had hypertension never 2.2 GNC balanced Urine production
routin control. Known Avoid Calcium Phospor
had kidney disease nephrotoxic drugs
since 1 day before Plan to
admission was Hemodialise
performed hemodialise elective
last night

PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm
Lab:
Ur: 78 32 mg/dL
Cr: 3.06 2.03 mg/dL

Abdominal USG
-Chronic
parenchimatous renal
disease bilateral
-BPH grade II

5
Male 70 yo: 3. 3.1 primary fundusc Plan to give oral -VS
Ax: Hipertensi 3.2 secondary opy antihypertensio -Subjective
Had hypertension on n if patient was
didn’t know when he stable
suffered this condition,
poorly control.

PE:
BP: 150/90
PR: 56 bpm
RR: 20 tpm
Male 70 yo: 4. anemia 4.1 chronic disease Blood Threat as above -VS
Ax: normochr 4.2 def EPO smear, -Subjective
Decrease of appetited om reticulos - DL/3 days
since 10 days ago. normocite ite
Had hypertension not r
routin control
Diagnose CKD yesterday
and was performed
hemodialise

PE:
Pale conjungtive (-)

Lab:
Hb:
MCV: 91.20
MCH: 29.80
Male 70 yo: 5. 5.1 PUD Inj -VS
Ax: dispepsia 5.2 Uremic Metoclopramid -Subjective
Decrease of appetied syndrom gastropathy 3 x 10 mg iv
10 days ago, nausea Inj Omeprazole
and vomit 1 times 1 x 40mg iv

PE:
Tenderness (-)

Lab:
Ur: 78 32 mg/dL
Cr: 3.06 2.03 mg/dL