Morning &

Duty
Report
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

 Yulnova/ Male/ 62 y.o /HCU - 13

Chief Complaint:
• Breathlessness increased since
1
3 days ago
Present Illness History

• Breathlessness increased since 3 days ago,

had been felt since 1 weeks before, not
interfered by activity, food or weather. Sleep
comfortable with one pillow. History wake-
up at midnight because of breathlessness (-)
• Fever since 6 days ago, high, no chill, but
today fever not found
• Cough since 3 days ago, not sputum or bleed
Present Illness History

• Decrease of appetite since 1 week ago

• Nausea and vomite since 5 days ago, but now,
no nausea and vomite
• Epigastric pain since 3 days ago
• Mixturition was decreased since 3 days ago
• Swollen in extremities since 3 days ago
• Defecation is normal
• Patient was hospitalized in 3 days ago and got
thrombocyte 5 unit because of
thrombocytopenia (tr: 9.000)
Past Illness History

• History of Diabetes Mellitus (-)

• History of Hypertension (-)
• History of tuberculosis (-)

Family Illness History

• There is no family with the illness

Physical Examination

• General Appearance : Moderate

• Consciousness level : CMC

• BP : 135/91 mmHg
• HR : 90 x/minute
• RR : 19 x/minute
•T : 36,7 º C
• SaO2 : 96% on O2 3 L/mnt
• Eye
– Conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus in right hemithorax decrease start in ICS IV
– Percussion: dull in right hemithorax start in ICS IV
– Auscultation: bronchovesicular, Rhonchi +/+ Wh -/-
• Cor: VII
–Inspection : ictus is not seen
–Palpation : ictus is palpated at 1 finger
medial LMCS ICS V
–Percussion:
•Left border : 1 finger medial LMCS ICS V
•Right border: linea sternalis dextra
•Upper border: ICS II
–Auscultation: regular, murmur (-)
• Abdomen: VII
–Inspection : enlargement (-)
–Palpation : hepar and spleen is not palpable, pain in
epigastric (+)
–Percussion : shifting dullness (-)
–Auscultation : bowel sound (+) N

• Extremities:
–Oedema pretibia +/+
–Physiologic Reflex +/+
–Pathologic Reflex -/-
Laboratory Items Value
Hb 11,8 gr/dl VII
Ht 32 %
WBC 19.350/mm3
Platelet 22.000/mm3
Diff. Count 0/0/15/73/6/3
PT/APTT 11,5/32
RBG 67 mg/dL
Ur/Cr 18/11/2021  95/1,8 mg/dL
Ur/Cr 21/11/2021  193/4,7 mg/dL
SOGT/SGPT 55/25
Na/K/Cl 117/3,5/87
Alb/glob 1,9/2,1
BGA 7,47/24,9/85,3/18,6/-5,4/96,5
HbsAg/Anti HCV/Anti HIV NR/NR/NR
Chest X-Ray VII
ECG VII
Check the protein urine VII

Before After (Protein +3)

Problems
• Breathlessness
• Pneumonia
• Kidney disease
• Pleural effusion
• Leukositosis
• Hyponatremia
• Hypoalbunemia
Working Diagnosis
• Hospital Acquired Pneumonia
• Acute Kidney Injury Stage III cb prerenal cb dehydration
DD Acute on Chronic Kidney Disease
• Thrombocytopenia cb secondary DD DHF DD ITP
• Hyponatremia cb Renal loss DD gastrointestinal loss
• Pleural effusion dextra
• Hypoalbuminemia cb renal loss
• Hypocalsemia cb renal loss
• Syndrom dyspepsia type like ulcer
Therapy
• Rest/ soft diet low salt low protein 48 gr
• O2 3 L/I via nasal canul
• IVFD NaCl 3% 500cc/12 hours (2 kolf)
• IVFD NaCl 0,9% 500cc/12 hour
• Inj. Cefepime 3x1 gr (i.v)
• Inf. Levofloxacin 1x500mg IV (d-1)  then 1x250mg (d-2,dst)
• Tranfusion albumin 25% IV
• Paracetamol 3x500mg
• Asetilcistein 3x200mg
• Lansoprazol 1x30mg
• Sucralfat 3x2 cth
• Folic acid 1x5mg
• Bicnat 3x500mg
• Fluid balance positif
Plan
• Check IgM, IgG Anti dengue
• Culture Sputum
• Kidney USG
• Lung USG