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    Duty Report: Dr. Rudi Erwin

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    RudiErwinKurniawan
    Dr. Rudi Erwin examined 55-year-old male patient Firdaus who presented with increased shortness of breath, cough, fever, and swelling of the foot for the past month. On examination, the patient had tachycardia, tachypnea, and signs of lung infection. Laboratory tests showed anemia and kidney failure. The working diagnoses were CKD stage V with acute lung edema due to infection and uncontrolled diabetes. The patient was started on antibiotics, insulin, and other medications and planned for further tests and dialysis.

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    Duty Report: Dr. Rudi Erwin

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    RudiErwinKurniawan
    37 views12 pages
    Dr. Rudi Erwin examined 55-year-old male patient Firdaus who presented with increased shortness of breath, cough, fever, and swelling of the foot for the past month. On examination, the patient had tachycardia, tachypnea, and signs of lung infection. Laboratory tests showed anemia and kidney failure. The working diagnoses were CKD stage V with acute lung edema due to infection and uncontrolled diabetes. The patient was started on antibiotics, insulin, and other medications and planned for further tests and dialysis.

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    Duty Report

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    Dr. Rudi Erwin examined 55-year-old male patient Firdaus who presented with increased shortness of breath, cough, fever, and swelling of the foot for the past month. On examination, the patient had tachycardia, tachypnea, and signs of lung infection. Laboratory tests showed anemia and kidney failure. The working diagnoses were CKD stage V with acute lung edema due to infection and uncontrolled diabetes. The patient was started on antibiotics, insulin, and other medications and planned for further tests and dialysis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    37 views12 pages

    Duty Report: Dr. Rudi Erwin

    Uploaded by

    RudiErwinKurniawan
    Dr. Rudi Erwin examined 55-year-old male patient Firdaus who presented with increased shortness of breath, cough, fever, and swelling of the foot for the past month. On examination, the patient had tachycardia, tachypnea, and signs of lung infection. Laboratory tests showed anemia and kidney failure. The working diagnoses were CKD stage V with acute lung edema due to infection and uncontrolled diabetes. The patient was started on antibiotics, insulin, and other medications and planned for further tests and dialysis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 12

    DUTY REPORT


    Nov 29th ,2017

    dr. Rudi Erwin


    Firdaus, Male, 55yo, MW03

     Cc:

     Shortness of breath increased since 1 day ago

     Present Illness History


     Shortness of breath increased since 1 day ago. Shortness of breath
    affected by activity and not affected by weather and food. PND (-), DOE
    (-), OP (-).
     Swelling of the foot since 1 month ago.
     Pale since 1 month ago.
     Cough since 1 week ago. Sputum (+). Bloody cough (-).
     Nausea and vomite denied
     History of bleeding (-)
     Fever since 3 days ago. Not too high. No chill and no exessive sweating.
     Micturation and defecation normal
     Patient has been known CKD stage V on regularly HD.

    Past Illness History
    • History of DM (+) since 10 years ago. Regularly controlled
    • History of HT (+) since 3 years ago. Regularly controlled

    Family Illness History


    • Nothing family with the same of diasease
    Physical Examination

     Consciousness level : CMC

     BP : 160/100 mmHg

     HR : 120x/minute

     RR : 28x/minute

     T: 36,9 C
     Eye
     Conjunctiva are anemic +/+
     Sclera are icteric -/-

     Neck 
     JVP 5-2 cmH20

     Lung:
     Inspection: simetric at statis and dinamic
     Palpation: fremitus difficult to examine
     Percussion: dull
     Auscultation: Bronchovesicular, rales +/+ , wheezing +/+

     Cor:
     Inspection: ictus not seen
     Palpation: ictus is palpated at 2 finger lateral LMCS RIC VI
     Percussion:
     Left border: 2 finger lateral LMCS ICS VI
     Right border: linea sternalis dextra
     Upper border: RIC II
     Auscultation: pure rhythm, no murmur
    Abdomen:

     Inspection: enlargement (-)
     Palpation: liver and spleen not palpable
     Percussion: tympani
     Auscultation: bowel sound (+)

    Extremities:
     Physiologic Reflex +/+
     Pathologic Reflex -/-
     Oedema +/+
    Laboratory

    Hb 7,9 gr/dl
    PH 7,23
    Ht 23% PCO2 49
    WBC 38.780/mm3 PO2 33
    Platelet 481.000/mm3 HCO3- 20,5
    MCV/MCH/MCHC 86/27/92 BEecf -7,1
    Ur/Cr 56/5,7 SO2 50%
    Na/K/Cl 140/3,7
    RBG 215


    Working Diagnosis
    Primary Diagnosis :

     CKD stage V cb Type 2 DM with Acute Lung
    Oedem

    Secondary Diagnosis :
     Septic cb HCAP with type 2 respiratory failure
     Type 2 DM uncontrolled normoweight
     Hypertensive heart disease
     Ischemic Myocard Inferior
     Moderete anemia normocytic normochrome cb
    chronic disease
    Therapy

     Rest /Low protein 50gr low salt II heart diet II DD 1700 kkal/
    O2 NRM 10L/1’
     Inj. Meropenem 3x1 gr (iv)
     Drip insulin continous 50 IU in 50cc NacL 0,9% (syringe pump)
    start fast 1cc/hour.
     Candesartan 1x16 mg (po)
     Amlodipin 1x10mg (po)
     Folic acid 1x5mg (po)
     Bicnat 3x500mg (po)
     Paracetamol tab 3x500 mg (po)
     N-acetylsistein tab 3x200 mg (po)
     Fluid balance
    Planning

     HD
     Sputum culture
     Blood culture

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