Duty Report 17 Desember 13
Transcript of Duty Report 17 Desember 13
8/12/2019 Duty Report 17 Desember 13
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December 17 th 2013
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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
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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 (-)/(-)
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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
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WD/:
Lymfadenophaty
Mild anemia micrositic hypocrom cb cronic
desease
DD/Lymfadenitis TB
Lymfoma malignum
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Rest/ Daily diet High calory high protein
PCT 500 mg (if needed)
NTR 2 x 1 tab
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X-ray lung
BAJAH
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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
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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 (-)/(-)
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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 %
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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
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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
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Exp. X-ray lung
Culture of sputum
Echocardiograpy
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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
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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
Lung : Bronchovesiculer, rales (+/+) wet, Whezzing (-/-)
Heart : ictus was palpable 2 finger lateral of LMCS RIC VI,
reguler rythm, Murmur (-)
Abdomen: Liver and spleen unpalpable, shifting dullnes (+)
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal Edem (+)/(+)
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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 %
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WD/:Stage V CKD Cb Nefrosclerosis Hypertension on
CAPD with metabolic AcidosisCHF fc. IV LVH RVH sinus rythm Cb HHD
Community acquired pneumonie
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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
Ambroxol syr. 3 x cth 2
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
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Exp. X-ray lung
Culture of sputum
Echocardiograpy
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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 (-)
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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
Lung : Bronchovesiculer, rales (+/+) wet, Whezzing (-/-)
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
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal Edem (-)/(-)
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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 %
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WD/:
Septic Cb Bronchopneumonia (CAP)
Evan’s Syndrome
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Rest/ Daily diet
IVFD NaCl 0,9 % 6 hrs/kolf
Ceftriaxone inj. 1 x 2 gr ( skin test )
Ciprofloxacin inf. 2 x 200 mgParacetamol 3x 500 mg tab
Ambroxol syr. 3 x cth 2
Curcuma 3 x 1 tab
Transfusion WRC until Hb >= 7 gr/dL
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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
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- 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
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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 : -
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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
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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
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- 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
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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
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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 (-)
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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 (+)
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal
Edem (-)/(-)
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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
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WD :
ALL
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Rest/ soft diet/O2 3 l/I
IVFD NaCl 0,9 % 8 hrs/kolf
Ceftriaxon 1x2 gr ( skin test )
Paracetamol 3x 500 mg tabNeurodex 3x1 tab
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BMP
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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
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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
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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
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WD :
Gastropathy NSAID
Type 2 DM uncontrolled overweigh
DD: gastropharese DM
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Th :
Rest/ DD 1500 kkal
IVFD NaCl 0,9 % 8 hrs/kolf
Lansoprazol 1x1 ampSucralfat syr 3x1 C
Solosa 1x2 mg
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esophagogastroduodenoscopy