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DUTY REPORTJANUARY 22TH 2014
Doctor in charge: dr.Rizky dr.ArlisCoass in charge: Try, Nurmalida
PATIENT RECAPITULATIONInpatient: 6 patientsOutpatient: 3 patientsWard: 3 patients
Patientss IdentityName: Mr.DSex: MaleAge: 51 y.oJob : TNI ADReligion: IslamMarital status: MarriedAddres: BTN KORPRI
ANAMNESISAutoanamnesa on January 22nd 2014 at 8 PM in the ER at RSPAD Gatot Subroto
Chief complain: noneadditional complain: none
CURRENT ILLNESSPatient was reffered to RSPAD with achalasia. 5 years before admission he felt dysphagia, nausea-vomit. And get worsed the last 2 weeks. Vomit, fever, abdominal pain were denied, defecation normal, urination normal
PAST ILLNESSHypertension (2013, uncontrolled)Heart desease deniedDiabetes deniedUric acid deniedCronic cough denied
Family illnessHypertension deniedHeart desease deniedDiabetes deniedStroke deniedMalignancy denied
Habits and lifestyleHeavy smoker for 10 years ( 1 2 packs a day )Stopped 5 years
Physical examinationVital signGeneral state: moderate sicknessConsciousness: compos mentisBlood pressure: 220/110 mmHgPulse: 75 bpmRespiratory rate: 24 bpmTemperature: 36 oCBody weight: 50 kgBody weight: 160 cm
Physical examinationGeneral examinationHead : Normocephaleye:anemic conjunctiva (-/-), icteric sclera (-/-)Ears:normotia, discharge (-/-)Nose: Septum deviation (-), discharge (-)Mouth: Oral trush (-), leukoplaki (-)Neck: lymph nodes enlargement (-)Thorax:symetric, intercostal retraction (-)
Diagnostic plan LABORATORIUM
ResultNormal RangeHb12.513-18 G/DLHt3540-52%Erithrocyte4.24.3 - 6.0 Juta/nlLeukocyte88004.800 10.800/nlThrombocyte204000150.000 400.000/nlMCV8220 96 flMCH3027 32 pgMCHC3632 36 g/dl
ureum18020 50 mg/dLCreatinin4,60,5 1,5 mg/dLRBS (Random Blood Sugar)90
ECG
Esophagus duedonoscopy
RESUMEPatient was admitted into ER at 8 PM. Patient was reffered to RSPAD with achalasia. 5 years before admission he felt dysphagia, nausea-vomitting. And get worsed the last 2 weeks. Patient have hypertension since 2013, uncontrolled.On physical examination, blood pressure 200/110 mmHg. And on additional examination there are find Ureum: 180 mg/dL Creatinin: 4,6mg/dLKalium: 5,5 mmol/L
PROBLEM LISTAchalasiaEmergency hypertensionAcute kidney injury
ASSESSMENTEmergency hypertensionPhysical examination: blood pressure: 200/110 mmHgAdditional examination:Ureum: 180 mg/dLCreatinin: 4,6 mg/dLKalium: 5,5 mmol/L
Acute kidney injuryUreum: 180 mg/dLCreatinin: 4,6 mg/dLKalium: 5,5 mmol/L
TherapyIVFD RL 10 dpmISDN 5 mg SL
PrognosisQua ad vitam: dubia ad bonamQua ad functionam: dubiaQua ad sanationam: dubia