Duty Report 17 Desember 13

8/12/2019 Duty Report 17 Desember 13

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December 17 th 2013



CC : Bump at aboth folding thigh 1 months ago

Present illness history: Bump at aboth folding thigh 1 months ago. Multiple blump,

size measure equal to lizard egg

Bump also find in left axilla and right neck each 1, size

measure equal to lizard egg History of long Cough (-)

Fever (-)

Breathlessness (-)

Nausea and Vomite (-) Pale since 1 moths ago

Increased apetite (-)

Decreased Weight Body since 1 months ago, but patient

don’t know how much to decreased

Urinate and defecation were usual



Consc : fully alertBP : 130 /80 mmHg HR : 80 x/’

RR : 20 x/’ T : 36,4 0 C

Eye : Conjuctiva anemic (+),sclera icterus (-)

Lymph gland :

Inguinal Bilateral : palpable lymp multiple, size 0,4 x 0,3 cm,chewy, mobile, no pain

Left Axilla : palpable 1 lymp, size 0,4 x 0,3 cm, chewym

mobile, no pain and in the right neck too

Neck : JVP 5-2 mmHgLung : vesiculer, rales (-/-) , Whezzing (-/-)

Heart : ictus was palpable 1 finger medial of LMCS RIC V,

Murmur (-)

Abdomen: Liver and spleen unpalpable

Ext : FR :(+)/(+) Normal, PR:(-)/(-) Normal Edem (-)/(-)



Hb : 10,6 gr/dl

Leu : 27.200 /mm3

Na : 142 mmol/L

K : 3 mmol/LMCH/MCV/MCHC : 24,8/74/33,4

Ureum : 15 mg/dl

Creatinin : 0,8 mg/dL



WD/:

Lymfadenophaty

Mild anemia micrositic hypocrom cb cronic

desease

DD/Lymfadenitis TB

Lymfoma malignum



Rest/ Daily diet High calory high protein

PCT 500 mg (if needed)

NTR 2 x 1 tab



X-ray lung

BAJAH



CC : Fever since 2 days ago

Present illness history: Fever since 2 days ago, High, continous, no chill, no sweat

Cough since 2 days ago, yellow sputum

Yellow skin since 2 days ago

Vaginal bleeding since 3 months ago with long of

menstruation

History of bleeding of gum (-)

Epistaksis (-)

History of contusio skin since 3 month ago History black stool 3 days ago, but had stop since

yesterday

Patient move from Obgyn with vaginal bleeding for 3

months, and get transfution Trombocyte 10 unit and PRC 3unit



Consc : fully alert

BP : 110 /60 mmHg

HR :108 x/’

RR : 28 x/’

T : 38,5 0 CEye : Conjuctiva anemic (+),sclera icterus (-)

Neck : JVP 5+2 mmHg

Lung : Bronchovesiculer, rales (+/+) wet, Whezzing (-/-)

Heart : ictus was palpable 1 finger lateral of LMCS RIC VI, Abdomen: Liver palpable 2 finger BAC, 4 finger Bpx, flat

surface , blunt edge, Chewy ,bruit (-) and spleen S2

Ext : Fisiology reflex :(+)/(+) Normal

Pathology reflex:(-)/(-) Normal Edem (-)/(-)



Hb : 5,2 gr/dl

Leu : 19.900 /mm3

Ht : 20 %

Trombosit : 2000 /mm3Na : 140 mmol/L

K : 3 mmol/L

APTT/PT : 43,3 “/ 12,5 “

D-dimer : 1,9

AGD : pH : 7,48 pCO2 : 26 P O2 : 161

HCO3- : 19,4 BE : -4,1 Sat. O2 : 100 %



WD/:

Septic cb HAP with type 1 respiratoty failure

Severe anemia normocitic normokrom cbacute bleeding cb methorragia

Trombositopenia

CHF fc. IV LVH RVH sinus rythm Cb AHD



Rest/ Heart diet II / NRM 10 l/I

IVFD NaCl 0,9 % 6 hrs/kolf

Ceftazidine 2 x 1 gr ( skin test )

Levofloxacin inf. 1 x 500 mg Transamin inj. 3 x 1 amp

Vit K inj. 3 x 1 amp

Dexametason inj. 2 x 1 amp

Paracetamol 3x 500 mg tab

Ambroxol syr. 3 x cth 2

Transfution trombocyte 10 unit and PRC until

Hb>= 7



Exp. X-ray lung

Culture of sputum

Echocardiograpy



CC : Breathlessness increase since 1 days ago

Present illness history: Breathlessness increase since 1 days ago. Its increase

with activity and decreased with rest

History of wake up by breathlessness (-)

Patient have been recognized to suffer to failure kidney

since last 2 year and have been attached CAPD since 1

years ago

Cough since 2 days ago, white sputum, no blood Fever denied

Urination and defecation were usual

History of Hypertension since 20 years ago



Consc : fully alert

BP : 170 /90 mmHg

HR : 88 x/’

RR : 26 x/’

T : 36,2 0 CEye : Conjuctiva anemic (+),sclera icterus (-)

Neck : JVP 5+5 mmHg


Heart : ictus was palpable 2 finger lateral of LMCS RIC VI,

reguler rythm, Murmur (-)

Abdomen: Liver and spleen unpalpable, shifting dullnes (+)


Pathology reflex:(-)/(-) Normal Edem (+)/(+)



Hb : 7,3 gr/dlLeu : 13.200 /mm3Ht : 21%Trombosit : 230.000 /mm3

Na : 139 mmol/LK : 5 mmol/LUreum : 152 mg/dLCreatinin : 18,1mg/dL

CCT : 4,36

AGD : pH : 7,32 pCO2 : 32 P O2 : 129HCO3- : 16,5 BE : -9,5 Sat. O2 : 96 %



WD/:Stage V CKD Cb Nefrosclerosis Hypertension on

CAPD with metabolic AcidosisCHF fc. IV LVH RVH sinus rythm Cb HHD

Community acquired pneumonie



Rest/ Low protein diet 50 gr/ Low salt II/Heart diet II/ O2 2l/1 IVFD NaCl 0,9 % 12 hrs/kolf

Ceftriaxone inj. 2 x 1 gr ( skin test )

Lasix inj. 1 x 1 amp

Azitromycin 1 x 500 mg Amlodipin 1 x 10 mg

Paracetamol 3x 500 mg tab


Bicnat 3 x 500 mg

Folic acid 1 x 5 mg

Kalitake 3 x 1 sachet

Correction meylon 100 meq in 100 cc NaCl 0,9 % fast drip



Exp. X-ray lung

Culture of sputum

Echocardiograpy



CC : Fever increase since 3 days ago

Present illness history: Fever increase since 3 days ago, high, continue,

no shivering and sweatCough since 3 days ago, white sputum, no blood

Nausea since 1 weeks ago

feet felt to be chilled since 1 weeks ago

Bone pain since 5 days agoYellow eyes since 3 days ago

Urination like tea since 1 weeeks ago

Defecation usual, black stool (-)



Consc : fully alert

BP : 100 /60 mmHg

HR : 84 x/’

RR : 24 x/’

T : 39,4 0 CEye : Conjuctiva anemic (+),sclera icterus (+)

Neck : JVP 5-2 mmHg


Heart : ictus was palpable 1 finger medial of LMCS RIC V,

reguler rythm, Murmur (-)

Abdomen: Liver palpable 1 Finger BAC,flat surface, blunt

edge, pain (-) and spleen So


Pathology reflex:(-)/(-) Normal Edem (-)/(-)



Hb : 3 gr/dlLeu : 6700 /mm3Ht : 9 %Trombosit : 97.000 /mm3RBG : 130 mg/dL

Na : 140 mmol/LK : 2,9 mmol/LUreum : 18 mg/dLCreatinin : 0,7 mg/dLSGOT : 100 u/L

SGPT : 116 u/L AGD : pH : 7,55 pCO2 : 22 P O2 : 155

HCO3- : 19,2 BE ecf: -3,2 Sat. O2 : 100 %



WD/:

Septic Cb Bronchopneumonia (CAP)

Evan’s Syndrome



Rest/ Daily diet


Ceftriaxone inj. 1 x 2 gr ( skin test )

Ciprofloxacin inf. 2 x 200 mgParacetamol 3x 500 mg tab


Curcuma 3 x 1 tab

Transfusion WRC until Hb >= 7 gr/dL









Minsar,56yo, male

Cc : chest pain increased since 3 hours ago

Present illness history:

- Chest pain increased since 3 hours ago, referredto the neck,felt choking, breathlessness, duration

about 20 mnt. It was first complain, the patient

never felt like this before

- There was no Breathlessness, eventhough

breathlessness when activity and at the night

- There was no history of Oedema at the leg



- Black vomite since 4 days ago, frek 2-

3x/days, vol ¼ glss. Initially vomite consist

of food but become bloody at later.- Black stool since 4 days ago, frek 2x/day

- History of analgetic drug consumption 3

years ago, for 2 years.

- History of epigastric pain since 1 years

ago, could pointed the pain,not influenced

by food and drug

- There was no cough- There was no fever

- Mixturation was no complain



Rhytym : sinus

HR : 96 x /1’

Aksis : normal

Gel P : normal

PR interval : 0,12 sec

QRS komplek : 0,08 sec

ST depresi : V2-V6Q patologis : -

Sv1+Rv6 <35 mm

R/SV1 <1

T inverted : -



WD/: unstable angina pectoris

hematemesis melena cb peptic ulcers

moderate normositic normochromanemia cb acute bleeding

Stage I hypertension cb essensial

DD/ : NSTEMI

GERD

Hematemesis melena cb gastertumour

Dyspepsia non ulcers

Dyspepsia Functional



Yuniar

Cc : decreased concioussness since 1 day

agoPresent illness history:

- Decreased concioussness since 1 day

ago, suddenly, without cold sweaty

- Cough since 7 days ago, phlegm (+),

yellowish, no blood.

- Fever since 3 days ago, not continue, no

chill, no sweaty- Breathlessness was denied



- The patient had been known as diabetes

patient since 10 years ago, never been

control since 1 years ago.- Hypertension history was denied

- Defecation & mixturation were normal



WD/: decreased of concioussness cb ACS

BP duplex (CAP)

Type 2 uncontrolled Diabetes Mellitusnormoweight

RBBB complete

ischemia myocard anteroseptal

DD/: decreased of concioussness stroke

infark



Cc : gum bleeding since a week ago

Present illnes history :Gum bleeding since a week ago, not profusePale since 3 weeks ago, firstly complain since

2 months ago and have had bloodtransfussion 3 weeks ago in Yos Sudarsohospital

Fever since 2 months ago, not continous, nochill, no sweatNausea (-), vomit (-)



Consc : fully alert

BP : 120 /70 mmHg

HR :109 x/’

RR : 20x/’

T : 38,8 ‘C Eye : Conjuctiva anemic (+),sclera icterus (-)

Neck : JVP 5-2 mmHg

Lung : vesiculer, rales (-/-) wet, Whezzing (-/-)

Heart : ictus was palpable 2 finger medial of LMCS RIC V

Abdomen: Liver and spleen weren’t palpable, bowel sound (+)


Pathology reflex:(-)/(-) Normal

Edem (-)/(-)



Hb : 6,4 gr/dlLeu : 150.000 /mm3Ht : 21%

Trombosit : 38.000/mm3Blast : (+)Na : 131 mmol/LK : 3,2 mmol/L

Ureum : 14 mg/dlCreatinin : 0,6 mg/dl





WD :

ALL



Rest/ soft diet/O2 3 l/I


Ceftriaxon 1x2 gr ( skin test )

Paracetamol 3x 500 mg tabNeurodex 3x1 tab



BMP



Cc : pain at the upper left of the abdomen since 4days ago

Present illness history : Abdominal pain since 4 days ago

Nausea (+), vomit (-) Feeling bloated (+) Breathlessness (-)Mixturation was no complain Black defecation (-)

History of consumption of analgetic (piroxicam) forabout 3 months regularly The patient have been known suffer from dm since

8 years ago



Consc : fully alertBP : 130 /70 mmHgHR :80 x/’RR : 20x/’T : 36,3 ‘C

Eye : Conjuctiva anemic (-),sclera icterus (-)Neck : JVP 5-2 mmHgLung : vesiculer, rales (-/-) wet, Whezzing (-/-)Heart : ictus was palpable 2 finger medial of LMCS RIC V Abdomen: Liver and spleen weren’t palpable, bowel sound (+)Ext : Fisiology reflex :(+)/(+) Normal

Pathology reflex:(-)/(-) NormalEdem (-)/(-),sensibility was decrease



Hb : 11,7 gr/dlLeu : 9.500 /mm3Ht : 36%

Trombosit: 436.000/mm3RBG :249 mg/dlNa : 135 mmol/LK : 3,8 mmol/L

Ureum : 44 mg/dlCreatinin : 1,6 mg/dl



WD :

Gastropathy NSAID

Type 2 DM uncontrolled overweigh

DD: gastropharese DM



Th :

Rest/ DD 1500 kkal


Lansoprazol 1x1 ampSucralfat syr 3x1 C

Solosa 1x2 mg



esophagogastroduodenoscopy

Documents

Duty Report 17 Desember 13