Duty Report

Saturday, January 2nd 2019

.
Physician in charge
I  : dr.
II Intensive  : dr. Tia
II Non-Intensive : dr. Jefri
II HCU  : dr. Bunga
II UGD  : dr. Norma, dr. Meti
Chief on duty  : dr. Kathy
Consultant on duty  : dr. Herwindo Pudjo, SpPD

Mr S/ 58yo/ward 25. Bed 2.7

Autoanamnesa
Chief Complaint: General Weakness
History of Present Illness:
Patient came with general of weakness since 3 days ago. He couldn’t do activity like usual.
Usually he could work for 3 hours a day but now he only worked only about 2 hours and it was
only cutting the grass. These condition had been happening more than a year and finally a year
ago, due to this unsolved problem he went to doctor and he was diagnosed with ”jantung dan
paru bengkak” and there was something wrong with the kidney despite of his normal defecation
and urination. He usually defecated 1 time with normal consistency. He drank 2L per day and he
urinated very much. Due to this problem then he was referred to RSSA.
Patient had a routine HD twice a week every Monday and Thursday since a year ago and
finally 6 months ago he was diagnosed multiple myeloma. He got treated with regimen
chemotherapy and octabone 1x600mg, and the next chemotherapy schedule is 6/2/2018.
He never had hypertension and diabetes mellitus. His highest blood pressure was 120/80..
He took allopurinol everyday. There was no allergy.
Past Medical History:
Patient stated that he had sudden onset broken thigh, there was no trauma happened and it was
1 year ago.. He also said that he could sit since 6 months ago  but now he could sit and even
walked by himself
Family History:
He also denied same disease in closest relatives

Social History:

1
Patient worked as a farmer with 1 wife and 2 children. Patient had a history of smoking 24
cigarettes everyday for more than 20 years
Review of System:
-

Physical Examination

General appearance look Sat O2 98%onroom air

moderately ill VAS 0/10
GCS  456

BP 120/80 PR 80   bpm RR 20  tpm Tax  36oC

mmHg regular strong

Head Conjuctiva Anemic (+),  Sclera Icteric (-),

Neck JVP R+ 0 cmH20

Chest Symmetrical, retraction (-)

Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi :   - | - Wheezing :     - | -

Sonor | Sonor Vesicular | Vesicular            -|-      -|-

Sonor | Sonor Vesicular | Vesicular            -|-      - |-

Cardio Ictus invisible, palpable at MCL (S) ICS V

LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany

Extremities Edema (-), pale (-), MMT 5 | 5 ,  uremic frost (+)

                                            5 | 5

Laboratory Findings

LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 6960 4.700 – Ureum 50.1 20-40 mg/dL

11.300 /µL

Hemoglobin 5.4 11,4 - 15,1 Creatinin 5.29 <1,2 mg/dL

e g/dl e

2
PCV 16.7 38 - 42% eGFR 11ml/min

Thrombocyt 245.000 142.000 – Natrium 145 136-145 mmol/L

e 424.000
/µL

MCV 96 80-93 fl Kalium 3.63 3,5-5,0 mmol/L

MCH 31 27-31 pg Chlorida 111 98-106 mmol/L

Eo/Bas/Neu/ 4.3/0.0/67 0-4/0-1/51- Calcium 9.1 7,6-11,0

Limf/Mon .8/15.4/12 67/
.5% 25-33/2-5 Phospor 2.5

SGOT - 0-40 U/L

SGPT - 0-41 U/L

Albumin 3.70 3.5-5.5

g/dL
LAB VALUE NORMAL LAB  VALUE NORMAL

Turbidity 10 x

Color Yellow Epithelia 0,4 ≤1

pH 8,0 4.5 – 8.0 Cylinder -

1.005 – Hyaline
1.015 -
SG 1.030

Glucose trace negative Granular

Protein 2+ negative Other

Keton Negative negative

Bilirubin Negative negative 40 x

Urobilinog Negative negative Erythrocyt 0,4 ≤3

3
en e

Nitrite Negative negative Leukocyte 2,2 ≤5

Leukocyte Negative negative Crystal

Erythrocyt Trace- Bacteria

negative 22,7x103 ≤23 x 103/ml
e Intact

Other

 ECG : Sinus Rhythm with HR 80bpm with axis CWR

4
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr S/ 58yo/ward 25 1. 1.1 Multiple β-2 Non- Pharmacologic CBC post

Subjective Anemia Myeloma Microglobu -Bed rest transfusion,
General weakness (+), HD Gravis 1.2Macrocytic lin BMP -IV plug transfusion
routine, sudden onset of Megaloblastic -Renal diet, low salt <2gr, low protein 0,8- reaction,
broken thigh (+)  had been Anemia 1,0/kgBB/day KIE about the
diagnosed Multiple Pharmacologic disease and
Myeloma -Folic acid 1x1 PO prognosis
Objective -Vitamin B6/B12 3x1
Conjunctiva anemis (+) -Transfusion PRC 2 lb/day until Hb> 8g/dL
Laboratory
Hb: 5,4g/dL
MCV/MCH: 91/31
Ur/cr: 50,1/5,29mg/dl
eGFR: 11ml/min

Mr S/ 58yo/ward 25 2. CKD St 2.1 Due to Multiple - Non- Pharmacologic Subjective,

Subjective V on myeloma -Bed rest Objective, urine
Had routine HD (+), routine -IV plug ouput, KIE to
general weakness, HD - Renal diet, low salt <2gr, low protein 0,8- get AV shunt
hypertension (-), diabetes 1,0/kgBB/day
mellitus (-) Pharmacologic
Objective -HD as scheduled

BP: 120/80mmHg
Anemic conjunctive (+)
Uremic frost (+)
Laboratory
Hb: 5,4g/dL
MCV/MCH: 91/31

5
Ur/Cr: 50,1/5,29mg/dl
eGFR: 11ml/min

Mr S/ 58yo/ward 25 3. - - Non- Pharmacologic KIE about the

Subjective Multiple -Bed rest disease and
General weakness (+), HD Myeloma -IV plug prognosis
routine, sudden onset of -Renal diet, low salt <2gr, low protein 0,8-
broken thigh (+)  had been 1,0/kgBB/day
diagnosed Multiple Pharmacologic
Myeloma --Chemotherapy as scheduled and Octabone
Objective 1x600mg
Conjunctiva anemis (+)
Laboratory
Hb: 5,4g/dL
MCV/MCH: 91/31
Ur/cr: 50,1/5,29mg/dl
eGFR: 11ml/min