Duty Report Co Asisten at Departmen Internal Medicine Indonesia Army Central Hospital Gatot Soebroto (Hospital Education Responsibility)

1. Resident on duty : dr. Wahyu
Coass on duty : Monica, Kara
Supervisor : dr Soroy Lardo SpPD FINASIM
DUTY REPORT
FEBRUARY 5TH
2014
CKD AND HHD
DEPARTMENT OF INTERNAL MEDICINE
INDONESIA ARMY CENTRAL HOSPITAL GATOT SOEBROTO

2. PATIENT RECAPITULATION
Ward : 2 new patients
6th
floor : 1 new patient
Mr. JL, 42 yo, Dx: observation on febris day 5 ec DHF dd/
Typhoid fever.
5th
floor : 1 new patient
Mrs. SS, 48 yo, Dx: CKD stage V with anemia normocytic
normochrom and acidosis metabolic; hyperkalemia; CHF fc
II ec HHD
4th
floor : -
3rd
floor : -

3. PATIENT’S IDENTITY
Name : Mrs. SS
Sex : Female
Age : 48 years old
Job : Housewife
Religion : Moslem
Marital Status : Married
Address : Perumahan Graha Prima Blok
Mawar 27 No 18 Bekasi

4. ANAMNESIS
Autoanamnesis on February 5th
2014 at 10.30 PM
Chief Complain:
General weakness since Monday
Additional Complain:
Dry cough

5. CURRENT ILLNESS
Patient was admitted to ward with general weakness
since Monday. Her complain became worsen day by day and
she couldn’t continue her daily activities.
She also complained of having dry cough without blood
since Monday. She denied any fever, shivering, night sweat
and unexplained weight loss.
There was history of dyspnea 2 days ago, DOE
(-), OP (-), PND (-), chest pain (-), excessive sweating (-),
nausea (-) and vomiting (-).
There was also history of swollen legs 4 days ago. There
were no complains of micturition and defecation, the quantity
are within normal limit. Fluid balance of input and output was
equal.

6. CURRENT ILLNESS
Patient was diagnosed with Chronic Kidney Disease
stage V. She was suggested to have hemodialysis but she
refused because she thought that she is in good condition.
She suffered hypertension for 4 years and take
routine medications with Amlodipine 1 x 10 mg and
Valsartan 1 x 160 mg.

7. Past Medical History
Diabetes (-)
Cardiac disease (-)
Allergy (-)
No family member with the same symptom
Hypertension (-)
Diabetes (-)
Cardiac disease (-)
Allergy (-)
Family Medical History

8. PHYSICAL EXAMINATION
VITAL SIGNS
Consciousness :Compos Mentis
General State : Moderate Sickness
Blood Pressure :130/100 mmHg
Heart Rate : 112 x/minute, regular
Respiratory Rate : 22 x/minute, regular
Temperature : 37,9o
C
Body Weight : 42 kg
Body Height : 150 cm
BMI : 18.6 (normoweight)

9. PHYSICAL EXAMINATION
General Examination
Head : Normocephal
Eye : anemic conjunctiva (+/+), icteric sclera (-/-)
Ears : normotia, discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : pale lips, normal tongue, hyperemic pharynx (-), T1-
T1
Neck : lymph nodes enlargement (-), JVP 5-2 cmH2O

10. Thorax : normothorax, symmetric, intercostal retraction (-)
Cor :
Inspection : ictus cordis was not visible
Palpation : ictus cordis palpated
Percussion : right cardiac margin at 5th
ICS parasternal dextra line,
upper cardiac margin at 3rd
ICS parasternal sinistra line and left cardiac
margin at 5th
ICS anterior axillary line.
Auscultation : regular 1st
and 2nd
heart sound, murmur (-), gallop (-)
Pulmo : vesicular breathing sounds, rhonchi (-/-), wheezing (-/-)
Abdomen : flat, soft, tympani, no enlargement of liver & lien, bowel
sound normal, tenderness (-)
Extremities : warm, pitting edema (-), cyanosis (-)
CRT < 2 seconds

11. DIAGNOSTIC PLANS
RESULT NORMAL RANGE
Hb 6.8 13 - 18 g/dl
Ht 20 40 – 52 %
Erythrocyte 2.3 4.3 - 6.0 mil /ul
Leukocyte 6800 4800 - 10800/ul
Thrombocyte 183000 150000 - 400000/ul
MCV 87 80 – 96 fL
MCH 30 27 - 32 pg
MCHC 34 32 – 36 g/dL
LABORATORY TESTS (Feb 5th
2014, 08.50 AM)

12. RESULT NORMAL RANGE
Ureum 232 20-50/ mg/dL
Creatinine 3.8 0.5-1.5 mg/dL
Random blood
glucose
107 <140 mg/dL
Na 140 135-147 mmol/L
K 5.3 3.5 – 5.0mmol/L
Cl 105 95-105 mmol/L
Feb 5th
2014, 7.28 PM

13. Blood gas analysis
RESULT NORMAL RANGE
pH 7.287 7.37-7.45
pCO2 18.3 33-44 mmHg
PO2 132 71-104 mmHg
HCO3 8.8 22-29 mmol/L
BE -15.7 (-2)-3 mmol/L
O2 Saturation 94.9 94-98%
AGD
Feb 5th
2014, 9.50 AM

14. Rontgen Thorax
Cardiomegaly (CTR 55%)

15. ECG

16. ECG

17. ECG

18. ECG
Sinus rhythm, normoaxis, P wave normal, QRS rate
94 bpm, PR interval 0.09 s, QRS complex 0.06 s, ST
changes (-), T inverted on V1 and V2, AV block (-),
BBB (-), LVH (+), RVH (-) and prolonged QT (0.4 s).

19. RESUME
A patient, female, 48 years old, was admitted with general
weakness since Monday. There was dry cough. There were
history of dsypnea, DOE (-), OP (-), PND (-) and swollen legs.
Patient was diagnosed with CKD stage V but she refused to
undergo hemodialysis. Patient was diagnosed with hypertension
for 4 years and take routine medications (Amlodipine and
Valsartan).
Vital signs showed BP 130/100 mmHg, tachycardia (112 bpm)
and febris (37.9o
C). On general examination, there were anemic
conjuctivas, dry lips and left cardiac margin at 5th
ICS anterior
axillary line (shifting to the left). The laboratory findings showed
anemia (Hb 6.8), eritropenia (2.3), increased ureum (232),
increased creatinine (3.8), hyperkalemia (5.3) and acidosis
metabolic. The radiologic finding showed cardiomegaly.

20. PROBLEMS LIST
1. CKD stage V with anemia normocytic normochrom
and acidosis metabolic
2. Hyperkalemia
3. CHF fc II ec HHD

21. ASSESSMENT
1. CKD stage V with anemia normocytic normochrom
Based on:
Anamnesis : general weakness, history of dyspnea and
swollen legs.
Physical examination : anemic conjuctivas
Laboratory findings : anemia (Hb 6.8), eritropenia
(2.3), increased ureum (232), increased creatinine
(3.8); CCT 14.4, AGD: acidosis metabolic
(pH/pCO2/pO2/HCO3/BE:7.287/18.8/132/8.8/-15,7)

22. 2. Hyperkalemia
Based on:
Laboratory findings : hyperkalemia (5.3)

23. 3. CHF fc II ec HHD
Based on:
Anamnesis : swollen legs, patient suffered
hypertension for 4 years and take routine medications
with Amlodipine 1 x 10 mg and Valsartan 1 x 160 mg.
Physical examination : 130/100 mmHg, left
cardiac margin at 5th
ICS anterior axillary line
(shifting to the left)
Rontgen thorax : CTR 55%, ECG : LVH (+)

24. THERAPY
Diagnostic plan
Echocardiogram
Monitoring plan
Electrolyte post GIC admission
Check Hb post transfusion
Check blood gas analysis post BicNat therapy

25. Therapeutic plan
Gradually PRC transfusion 500cc
Glucose D40 50cc + Insulin 10unit IV + Ca Gluconas
1amp (GIC)
BicNat 100mEq for 4 hours
Lasix 3x2amp
Kalitake 3x1sacchet
Amlodipine 1x10mg
Valsartan 1x160mg

26. PROGNOSIS
Qua ad vitam : Dubia ad bonam
Qua ad functionam : Dubia ad malam
Qua ad sanationam : Dubia ad malam

27. THANK YOU