DUTY REPORT

12TH FEBRUARY 2014

Resident on duty
GP on duty
Co-Assistant on duty

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dr. Wahyu
dr. Widya
Dian, Nindya

PATIENT RECAPITULATION
Floor

Patient (8)

Mrs. Syamsiar, 67 years old, 2nd day of fever

Mr. Slamet, 71 years old, 1st day of fever, low intake in geriatric

Mrs. Maryati, 51 years old, hyperglycemia, bronchopneumonia

Mrs. Romlah, untreated AIDS , hyperglycemia, low intake, oral
candidiasis

Mrs. Sukinah, 74 years old with CHF FC III ec old anterior MCI with
hypoalbuminemia, 1st degree AV block and hypertension, hyperglycemia
on DM type II
Mrs. Jusna, dyspepsia with grade II hypertension
Mrs. Supartini, 64 years old, ascites ec cirrhosis hepatic

Mr. Suparno, 57 years old, hyperglicemia on type II DM, stage IV CKD

PATIENTS IDENTITY
Name
Sex
Age
Job
Religion
Marital Status
Address

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Mrs. S
Female
74 years old
Housewife
Islam
Married
Prumpung, East Jakarta

ANAMNESIS
Auto and alloanamnesis on February 12th 2014 at 9 PM in

the PU ward of RSPAD Gatot Soebroto.

Chief Complaint

:
swelling on both of her feet

Additional Complaint

night

Patient complain of

Difficulty of sleeping at

CURRENT ILLNESS
Patient was admitted into the PU ward at 6 PM
Patient referred into RSPAD from Hermina.
Patient complained of swelling on both of her feet from 1

week before admitted into the hospital. Patients feet

starting to swell and gradually followed by her stomach
and both of her hands.
Patient denied neither chest pain nor chest discomfort.
Patient often woke up at night and felt difficult to breath
from 1 month ago. Patient felt more comfortable sleeping
with a one pillow. PND (+), OP (-), DOE (-).
Patient denied any cough, fever, sweating at night and
loss of weight
Defecation and urination within normal limit

CURRENT ILLNESS
Patient has diabetes mellitus type II for 8 years, regularly

controlled by insulin (8-8-10) and regularly check her

illness to RSPAD every month.
Patient felt a tingling sensation on both of her feet for a
long time. Patient denied any visual and hearing loss.
Patient also has an uncontrolled hypertension for 10 years

PAST ILLNESS
Heart disease denied
Uric acid denied
Chronic cough denied

FAMILY ILLNESS
Heart disease denied
Diabetes denied
Malignancy denied
Stroke denied

HABITS AND LIFESTYLE

Smoking (-)

PHYSICAL EXAMINATION
VITAL SIGNS
General State
Consciousness
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Body Weight
Body Height
BMI

Moderate Sickness
:
Compos Mentis
:
145/60 mmHg
:
110 x/minute
:
21 x/minute
:
36,2oC
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50 kg
:
150 cm
:
22,22 (Normoweight)

PHYSICAL EXAMINATION
General Examination

Head
: Normocephal
Eye
: anemic conjunctiva (-/-), icteric sclera (-/-)
Ears
: normotia, discharge (-)
Nose
: septum deviation (-), discharge (-)
Mouth
: oral trush (-), leukoplakia (-)
Neck
: lymph nodes enlargement (-)
Thorax : symmetric, intercostal retraction (-)
Cor
: regular 1st and 2nd heart sound, murmur (-), gallop (-)
Pulmo
: vesicular breathing sounds, rales +/+ at basal

wheezing -/Abdomen
: distended (+), bowel sound within normal limit,
shifting dullness (+), hepar & lien not palpable, absence
of pain
Extremities
: CRT <2s, warm, pitting edema (+), clubbing (-),
cyanosis (-)

LABORATORY RESULTS
JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

Hb

13,0

13 - 18 g/dl

Ht

40

40 52 %

Erythrocyte

5.1

4.3 - 6.0 mil /ul

Leukocyte

9.000

4800 - 10800/ul

Thrombocyte

333.000

150000 - 400000/ul

MCV

77

80 96 fL

MCH

25

27 - 32 pg

MCHC

33

32 36 g/dL

Hematologi rutin:

JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

Albumin

3.0 ()

3.5 5.0 mg/dl

Ureum

68 ()

20 - 50 mg/dl

Creatinin

1.3

0.5 1.5 mg/dl

Random Blood Glucose

260 ()

< 140 mg/dl

Sodium

129 ()

135 147 mmol/L

Potassium

4.1

3.5 5.0 mmol/L

Chloride

99

95 105 mmol/L

Acetone

-/Negative

-/Negative

Kimia klinik:

36 hours before

26 hours before

ECG

ST elevation on lead V1, V2, V3, V4.

Serial EKG persistent ST elevation
HR 84 x/m, sinus rhythm, normoaxis, QRS complex, 0.12s, PR

interval 0,22s 1st degree AV block

CHEST X-RAY (7th January 2014)

CTR 55% Congestion (-) Infiltrate (-)

Bilateral pleural effusion

RESUME
Patient complain of swelling on both of her feet from 1 week before

admitted into the hospital. Patients feet starting to swell and gradually
followed by her stomach and both of her hands. PND (+)
History of type II DM since 8 years ago, regularly controlled by insulin
(8-8-10), history of uncontrolled hypertension since 10 years ago
PE shows BP 144/60 mmHg, minimal rales at basal, ascites (+),
pitting edema on both lower extremities
LR shows hipoalbuminemia and hyperglycemia
Chest X-ray shows cardiomegaly
ECG shows old anterior MCI with 1st degree AV block

PROBLEMS LIST
Fuctional CHF grade III ec old anterior MCI with

hypoalbuminemia
Hypertension grade I
1st degree AV block
Hyperglycemia on DM type II

ASSESMENT

Functional CHF grade III e.c old

anterior MCI with hypoalbuminemia
Anamnesis
Bilateral swelling on both of her feet from 1 week ago
Paroxysmal Nocturnal Dyspnea/PND (+)
Physical examination
Rales +/+, pitting edema on both lower extremities
Additional examination
LR: Hypoalbuminemia, Chest X-ray: Cardiomegaly, ECG: Old anterior
MCI
Diagnostic plans
Chest X-ray
Echocardiography
Therapeutic plans
Furosemid 2x 20 mg

Hypertension Grade I
Anamnesis
History of uncontrolled hypertension since 1980
Physical Examination
Blood Pressure : 145/60 mmHg
Therapeutic plans
Captopril 3x6,25mg

1st Degree AV Block

ECG

Prolonged PR interval 0,22s

Hyperglycemia on DM type II
Anamnesis
History of controlled DM type II since 2006
PF
Parasthesia on both lower extremities
Laboratory result
RBG : 260 mg/dl
Diagnostic plans
FBG, PPBG, HbA1C
Therapeutic plans
Novorapid 3 x 4 unit

PROGNOSIS
Qua ad vitam
Qua ad functionam
Qua ad sanationam

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Bonam
Dubia
Dubia ad bonam

THANK YOU

Comments
Dr. Gatut
Dr. Gatut thinks the patient has a pleural effusion on 7th January 2014

and should be doing an serial chest x-ray to determine whether there is

still a pleural effusion or not because the pleural condition could be
much worse right now.
Dr. Dharmawan
Dr. Dharmawan thinks this patient should be given oral hyperglycemic

agent first, evaluate it then adjust the therapy based on the latest
laboratory results. However the therapy options can be adjusted according
the current clinical conditions and the physicians choice.
Insulin use indications
No effect from oral hyperglycemic agent
No effect from maximal dose of hyperglycemic agent
Organ disfunction (heart, liver, kidney)