DUTY REPORT

June 24th 2015

Resident on duty
GP on duty
:
Co-Assistant on duty

: dr. Cecep S. Sobur

dr. Widya
: Susasti and Fitriano

PATIENT RECAPITULATION
3rd Floor:
- Mrs. E (CKD on HD, pro CDL)
- Mrs. D (GEA)

4th Floor:
- Mrs. T (CKD on HD pro CDPA, SIDA

5th Floor:
- Mrs. E (Ca. Mammae pro TACE)
- Mrs. K (Ca. Mammae, low intake in psychiatric disorder)

6th Floor:
- Mr. S (Asites grade III, sirosis hepatis, CKD stage V)

PATIENTS IDENTITY
Name

: Mr. S

Age

: 48 years old

Job

: Soldier

Religion

: Islam

Marital Status : Married

Race

: Javanese

Address

: Tanggerang

Anamnesis
Chief complain:
Shortness of breath since 3 months before
admission

HISTORY OF PRESENT
ILLNESS
Patient has been feeling shortness of breath since 3 months before
admission. The patient feel that it gets better if sleeping on his side
and not much influenced by activity.
The patient also complained about the abdominal enlargement that
happened since three years ago. At the beginning patient admitted
that his abdomen started to enlarge since 7 years ago. The
abdominal enlargement reduced significantly after he got the fluid
from his abdomen being aspirated 3 years ago. Not long after that,
the abdomen has been back enlarged and not much increasing until
now.

 The patient admitted that he diagnosed hepatitis B and

cirrhosis hepatic about 7 years ago. The initial
complaint was jaundice, nausea, vomit and abdominal
enlargement. Patient also diagnosed renal dysfunction
since7yearsagoandhasbeenontherapyhemodialisys
sincethen.
There was no history of hematemesis, melena, or
hematochezia.
Patientadmittedthathisurinoutputaboutaquarterless
thantheamountofwaterthathedrank.

Past Illness
DM (-)
Lung disease (-)
Heart disease (-)

History of Family
Illness
HT (-)
Lung disease (-)
Kidney disease (-)
Allergy (-)

General Examination
Head

: Normocephal

Eye : anemic conjunctiva (+/+), icteric sclera (-/-)

Ears : discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : coated tongue (-), hyperemic pharynx (-),
normal T1-T1, pale mouth mucosa (-), dried mucosa
(-)
Neck : JVP 5 2 cmH2O, lymph nodes enlargement (-)

Physical
Examination
General State :Mildly sick
Consciousness

: GCS E4M6V5

Vital Signs
Blood Pressure
Heart rate

:150/100 mmHg

:86 bpm (regular)

Respiratory Rate :20 times/minute

Temperature

:36,7 oC

Body Weight

:52 kg

Body Height

:165 cm

BMI

:20,5 (Normoweight)

 Thorax: symmetric, intercostals retraction (-),

gynecomastia slightly found
COR

Inspection: Ictus cordis (-)

Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea parasternal dekstra
Left border : ICS V, linea midclavicularis sinistra
Heart waist: ICS III, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart

sound, murmur (-), gallop (-)

 PULMO

Inspection

chest

within

normal

shape,

symmetries on static and dynamic state. Spider

naevi (-)
Palpation : tactile vocal fremitus both lungs
were symmetries, chest expansion symmetries
Percussion : resonant both lungs
Auscultation : vesicular breathing decreasing
on the right side, rales (+/-), wheezing (-/-)

ABDOMEN
Inspection: distended (d=90 cm)
Palpation: soepel, hard nodul of the liver
palpated but the liver edge difficult to
palpate, spleen difficult to palpate
Percussion: shifting dullness +, tympani
to dullness
Auscultation: BU +

 Extremities : warm, icteric (-), leukonychia +, CRT

hard to evaluate, pitting edema (-), cyanosis (-),
palmar erithema not found,

LABORATORY RESULTS
Examination

Result

Normal lab

Hb

7.1

13 - 18 g/dl

Ht

21

40 52 %

Erythrocyte

2.4

4.3 - 6.0 mil /ul

Leukocyte

3400

4800 - 10800/ul

Thrombocyte

79000

150000 - 400000/ul

MCV

86

80 96 fL

MCH

29

27 - 32 pg

MCHC

34

32 36 g/dL

Haematology:

Examination

Result

Normal lab

Control

10.1

second

Patient

11.6

10.2 12.2 second

Control

35.1

second

Patient

44.2

29.0 40.2 second

1.00

0.8 -1.30

Coagulation:

PROTROMBIN TIME

APTT

INR

(Without anticoagulation therapy)

Examination

Result

Normal lab

SGOT (AST)

20

< 35 U/L

SGPT (ALT)

10

< 40 U/L

Albumin

3.8

3.5 5.0 g/dL

Ureum

73

20 - 50 mg/dl

Creatinin

10.1

0.5 1.5 mg/dl

Sodium

143

Potassium

3.9

135 147
mmol/L
3.5 5.0 mmol/L

Chloride

102

95 105
mmol/L

Resume
Male,48yearsoldcamewithchiefcomplainshortnessof
breathsince3monthsbeforeadmission.Itworseniflaying
downandbetterifsleeponhisside.
PatienthashistoryofhepatitisB,chirrosishepatica,
hypertension,CKDonHD.
Fromexamination:Bloodpressure150/100mmHg,anemic
conjungtiva,ascites(+)diameterofabdomen90cm,liver
nodulpalpated,shiftingdullness(+).Rhonkhi+/
Lab:ureum73,creatinin10,1

Problem List

1. Ascites grade III

2. Cirrhosis hepatic Child-Pugh Score? with
anemia normocytic normochrome
3. Chronic hepatitis B
4. CKD stage V on HD

Assesement
1. Shortness of breath suspect pleural
effusion and due to anemia

Based on:
-Patients complaints: shortness of
breath since 3 months before admission.
-PE: Respiratory rate 24 x/minutes.
Rhonchi (+) on the right side. Hb: 7.1
mg/dL.
-Diagnostic: Thorax rontgen

2.

Ascites grade III

Based on:
- Patients complaint: abdominal enlargement since
3 years ago
- PE: Abdomen diameter 90 cm, shifting dullness
(+), dullness percussion found lower part of the
abdomen
Diagnostic: USG abdomen
Therapy: Abdominal puncture (paracentesis)

3.

Cirrhosis hepatic
Child-Pugh Score?
with anemia
normocytic
normochrome

Based on:
- Patients history of chronic
hepatitis B
- PE: liver nodul palpated,
gynecomastia, leukonychia
totalis
Diagnostic: USG abdomen,
Lab serum bilirubin, serum
albumin to calculate CP score.
Lab Hb 7.1, MCH-MCV-MCHC
within normal limit
Therapy:

4. Hipertensi stage I
Based on:
PE 150/100 mmHg
Therapy: Captopril 25 mg 2 x 1

4. CKD stage V on HD
Based on:
Lab ureum 73 (increased), creatinin 10.1
(increased)
GFR (140-48) x 52 = 6,5
72 x 10,1

Prognosis
Quo ad vitam

dubia ad bonam

Quo ad functionam

dubia ad malam

Quo ad sanationam

dubia ad malam