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dr. Dian

DUTY REPORT

15 NOPEMBER 2013

dr. Dian, dr. Rini, dr. David

dr. Saras, dr. Eva

dr. Andri

dr. Sri Sunarti, SpPD

Mr. Abdu Rahman/62 years old/Ward 28

Anamnesis:

Chief complaint: weakness

History of Present Illness

Patient has became weak, unable to walk, and looked very sleepy since 12 hours before admission.Previously he has been suffering from mild grade fever and cough with yellowish sputum, and

decrease of appetite since 4 days ago. He didnt eat much because he felt nausea and his tongue felt

bitter. His cough actually occur more than 1 month but in moderate degree. He often felt shortness

of breath when he walk more than 20 meters. He also felt headache. He still consumed

glibenclamide 3 times 5 mg during his decrease of appetite. He used to had this symptoms about 2

months ago and at that time, his blood glucose level was very low, and he was hospitalized.

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Trachea in the middle

Mediastinum is normal

Hemidiaphragma: right is dome shape, left is dome shape

Costophrenical angle: right is sharp, left is sharp

Cardiothoraxis index: 60%

Cardiac waist +

Fibroinfiltrate in upper until lower part of both lungs

Conclusion: cardiomegaly (left ventricular hypertrophy) and lung tuberculosis

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PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue Problem List Initial DiagnosisPlanning

DiagnosisPlanning Therapy

Planning Monitoring

and Education

Male/62 years old

Anamnese:

Weakness, sleepy, consume

glibenclamid, low intake

Physical examination:

GCS: 2.3.3 at Emergency Room

HR: 120 beats/minute

Clammy acral at Emergency Room

Laboratory:

Random blood glucose level: 43 mg/dL

1.Hypoglicemia 1.1Due to druginduced(glibenclamid)

1.2Low intake

Has been

confirmed

Stop consuming

glibenclamide

Bolus Dextrose 40% 50

mL

Continued with infusion

of Dextrose 10% 1.500

mL/24 hours

After blood glucose level

reach 100-200 mg/dL,

change infusion intoDextrose 5% 1.500 mL/24

hours

After stable at blood

glucose level 100-200

mg/dL, change into NaCl

0,9% 1.500 mL/24 hours

Free diet

Monitoring:

SubjectiveVital signs

Random blood glucose

every 6 hours

Education:

Stop consume glibenclamid

Free diet for 2 days

Stop consume glibenclamid

when having decrease og

appetite

Male/62 years old

Anamnese:

History of diabetes mellitus for 2 years

Routinelly consume glibenclamid

2.Diabetesmellitus type

2 with

azotemia

Fasting bloodglucose level

2 hours post

pandrial blood

glucose level

Waiting for result offasting blood glucose

level and 2 hours post

pandrial blood glucose

level

Monitoring:Subjective

Vital signs

Fasting blood glucose level

2 hours post pandrial blood

glucose level

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Laboratory:

Ureum: 139,04 mg/dL

Creatinin: 3,06 mg/dL

HbA1c

Lipid profile

Uric acid level

Considering the

administration of insulin

Low calorie and low

glucose diet

HbA1c

Natrium, kalium, chloride,

calcium, phosphat

Ureum

Creatinin

Uric acidLipid profile

Urine production

Education:

Control routinely to

Endocrine Department

Low calorie and low

glucose diet

Male/62 years old

Anamnese:

History of hypertension

History of diabetes mellitus

Laboratory:

Ureum: 139,04 mg/dL

Creatinin: 3,06 mg/dL

BUN/creatinin: 21,22

3.Azotemia 3.1 Prerenalazotemia3.1.1 Dehydration

due to low intake

3.1.2 Due to heart

failure

3.2 Renal azotemia

3.2.1 Diabetic

nephropathy

3.2.2 Hypertensive

nephrosclerosis

Urine analysis

Fraction excretion

of natrium

Plasma specific

gravity

Urine specific

gravity

Abdominal

ultrasonography

Renal biopsy

Treat underlying disease Monitoring:

SubjectiveVital signs

Natrium, kalium, chloride,

calcium, phosphat

Ureum

Creatinin

Uric acid

Urine production

Urine analysis

Education:

Low salt diet

Male/62 years old 4.Heart failurestage C

4.1 Due to

hypertensive heart

Echocardiography Treat underlying disease Monitoring:

Subjective

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Anamnese:

Shortness of breath when walking far

distance, history of hypertension and

diabetes mellitus, history of

hospitalization in CVCU

Physical examination:

Ictus at 1 cm lateral midclavicular line

sinistra

Electrocardiography:

Left axis deviation

Chest X Ray: cardiomegaly (left

ventricule hypertrophy)

functional

class III

disease

4.2 Due to coronary

artery disease

4.3 Due to diabeticcardiomyopathy

4.4 Due to uremic

encephalopathy

Lipid profile

Coroner

angiography

Low salt and low fat diet Vital signs

Electrocardiography

Echocardiography

Education:

Low salt low fat diet

Male/62 years old

Anamnese:

History of hypertension and routine

consume captopril

Physical examination:

Ictus at 1 cm lateral midclavicular line

sinistra

Electrocardiography:

Left axis deviation

Chest X Ray: cardiomegaly (left

ventricule hypertrophy)

5.Hypertensionon treatment Blood pressure Amlodipin 1x5 mg tabletLow salt low fat diet

Monitoring:Subjective

Vital signs

Education:

Low salt low fat diet

Male/62 years old 6.Chronic 6.1 Lung tuberculosis Sputum gram, Ambroxol 3x30 mg Monitoring:

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