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.
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.
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.
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
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 (+)
