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  • Duty Report: August 8th, 2016

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    gina
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    A 33-year-old male presented to the emergency department with diarrhea, nausea, vomiting and fever for 1 day along with shortness of breath over the past 3 hours. He has a history of chronic kidney disease and hypertension requiring routine hemodialysis. On examination, he was tachycardic and tachypneic with a fever of 38.5 C. Lab work showed anemia and elevated white blood cell count. He was diagnosed with gastroenteritis and given IV fluids, antibiotics and medications to manage his chronic conditions.

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    Morning report

    Título original

    Zainal

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    A 33-year-old male presented to the emergency department with diarrhea, nausea, vomiting and fever for 1 day along with shortness of breath over the past 3 hours. He has a history of chronic kidney disease and hypertension requiring routine hemodialysis. On examination, he was tachycardic and tachypneic with a fever of 38.5 C. Lab work showed anemia and elevated white blood cell count. He was diagnosed with gastroenteritis and given IV fluids, antibiotics and medications to manage his chronic conditions.

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    © All Rights Reserved
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    7 vistas8 páginas

    Duty Report: August 8th, 2016

    Cargado por

    gina
    A 33-year-old male presented to the emergency department with diarrhea, nausea, vomiting and fever for 1 day along with shortness of breath over the past 3 hours. He has a history of chronic kidney disease and hypertension requiring routine hemodialysis. On examination, he was tachycardic and tachypneic with a fever of 38.5 C. Lab work showed anemia and elevated white blood cell count. He was diagnosed with gastroenteritis and given IV fluids, antibiotics and medications to manage his chronic conditions.

    Copyright:

    © All Rights Reserved
    Descargue como PPT, PDF, TXT o lea en línea desde Scribd
    Marcar por contenido inapropiado
    de 8

    Duty report

    August 8th , 2016


    Zainal, Male, 33yo

    Chief complaint
    diarrhea since 1 day ago
    Present illness history
    diarrhea since 1 day ago. With volume -
    cup, and with a frequency > 10x per day.
    Mucus (-), blood (-)
    Naussea accompanied by vomiting since 1
    day ago, frequency 4 times, containing food.
    Fever since 1 day ago. Continuously, high
    fever, no chills, and no sweating a lot.
    Short of breathness since 3 hours ago
    Cough (-)
    Patient had been known suffer CKD since 2,5
    years ago ang fet routine HD
    History of Hypertension since 2,5 years ago
    Physical Examination

    Consciousness level: CMC

    BP : 170 / 80 mmHg

    HR : 1 x/minute

    RR : 26 x/minute

    T: 38,5 C
    Eye
    Conjunctiva anemic -/-
    Sclera icteric -/-

    Neck
    JVP 5 - 2 cmH20

    Lung:
    Inspection: simetris sinistra = dextra
    Palpation: fremitus sinistra = dextra
    Percussion : sonor
    Auscultation: Vesicular, Rh - /-, wh - /-
    Cor:
    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: RIC II
    Auscultation: pure rhythm, murmur (-)
    Laboratory
    Hb 10,3 gr/dl
    Leukosit 12100 mm3
    Ht 33 %

    Platelets 191000mm3
    RBG 95
    Ur/cr 53/6,7
    Na/k 141/4
    WD
    GEA type choleriform without
    dehydration
    CKD stage V cb hypertension
    kidney disease on routine HD

    02/12/17
    Therapy
    Rest/ low salt II protein 50 gr low
    fibre / O2 3 L/i
    IVFD nacl 0.9% 8 hours/kolf
    Folic acid 1x 5mg
    Bicnat 3x 500 mg
    Amlodipine 1x 10 mg
    Candesartan 1x 16 mg
    Cotrimoxazole 2x 960 mg

    02/12/17

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