Duty Report March

Duty Report, Friday March 1st 2013

Duty Report, Wednesday March 13th 2013Dr. Arnaldo Eka PutraDr. Sri AnggraeniDr. Rizka RosalindaDr. Edo YudistiraDr. Farah SorayaDr. Guptaja Kusumah NCc: breathlessness since 1 week agoPresent Illness History:Breathlessness since 1 week agoEnlargement of the stomach since 2 months agoFatigue (+)The decrease of appetite (+)Patient has history of looking blueish when she criedWeni Wijayanti, female, 30 yo, HCU (dr. Arnaldo E P)Physical Examination:GA: moderateConsc: CMCBP: 100/60Pulse: 108xRR: 38xT: 36,8Eye: anemic conj (+/+), icteric sclera (-/-)Neck: JVP 5+2cmH2OPulmo: vesiculer, rales (-/-)Cor: ictus was palpable 1 finger lateral from ICR VI, M1>M2, P2 gastric diet IIVFD NaCl 0.9% 8h/kolfOzid vial 1x1Sucralfat syr 3xcth1Domperidone 3x10mgFluid balanceCc: breathlessness since 3 days agoPresent Illness History:Breathlessness since 3 days agoCough since 1 week agoVomit (+)Patient has been known having heart disease since 2 months agoGeno Yuliasri, male, 16 yo, MW-11 (dr. Arnaldo)Physical examination:GA: moderateConsc: CMCBP: 110/70Pulse: 98RR: 26T: 37.2Eye: anemic conj (-/-), icteric sclera (-/-)Neck: JVP 5+2cmH2OHeart: ictus was palpable 1 finger lateral from ICR VI, murmur (-), gallop (-)Lung: bronchovesiculer, rales +/+, wh -/-Stomach: liver and spleen were unpalpableExtr: edema -/-

Lab:Hb: 15.5Na/K/Cl: 123/3.9/92Leuco: 15000Ur/Creat: 41/0.8Ht: 45RBG: 179Trombo: 175000Urine : protein ++, keton -

WD:Bronchopneumonia (CAP)Dispepsia syndrome, dismotility typeCFH fc II LVH-RVH sinus rhythm cb Rheumatic Heart DiseaseHyponatremia cb vomitTherapy:Rest/heart diet II gastric diet IIIVFD NaCl 0.9% 12h/kolfCeftriaxone vial 1x2gr (skin test)PCT 3x500mgAmbroxol syr 3xcth2Ozid vial 1x40mgSucralfat syr 3xcth2Domperidone 3x10mgFurosemide 1x40mgCardace 1x2.5mgBisoprolol 1x2.5mgSpirinolacton 1x12.5mgErithromicine 2x250mgFluid balanceCeftriaxone vial 1x2gr (skin test)Ciprofloxacine drip 2x100mgMetronidazole drip 3x500mgPCT 500mg 3x1Amlodipine 5mg 1x1Candesartan 8mg 1x1Lasix amp 1x1Folic acid 5mg 1x1Bicnat 500mg 3x1Catheter fluid balanceRedressing twice a day

Toroi Manga, Male, 55 y.o, MWCC: Breathlessness since 3 days ago

Present Illness History:Breathlessness since 3 days ago. It was not affected by weather and activity.Patient was hospitalized on RSUD Padang for 10 days for the same symptom and ptekie on skin. Cough since 7 days ago, when patient hospitalizedFever since 2 weeks agoNausea and vomit (-)Physical Examination: GA: moderate, Consciousness: CMCBP: 140/80, Pulse: 88, RR: 32, Temp: 36,8C

Eyes : anemic-/-, icteric -/-Neck : JVP 5-2 cmH2OThorax : Lung : bronchovesiculer, Wh -/-, Rales -/- Cor : regular, murmur (-) Abdomen: liver not palpable Ext : oedem -/-

Lab: Hb : 11,3 g/dl , HT : 53%Leukocyte : 9900/mm3, Trombocite : 160.000/mm3

WD : Hospital Acquired PneumoniaSusp. VaricelaIO with Lung TB duplex

Therapy:Rest/Soft DietIVFD NaCl 0,9% 8 hours/kolfInj Ceftriaxon 1x2gr ivAmbroxol 3x1Paracetamol 3x500mgAmrizal, Male, 59 y.o, HCUCC : Fever since 2 days ago

Present Illness History:Fever since 2 days ago. Cough since 1 week agoBreathlessness (-)Patient has been known got kidney disease since 9 months ago and got Hemodialisa regularly Hypertension history since 5 years agoPhysical Examination: GA: moderate, Consciousness: CMCBP: 130/80, Pulse: 107, RR: 22, Temp: 38,2C

Eyes : anemic-/-, icteric -/-Neck : JVP 5-2 cmH2OThorax : Lung : bronchovesiculer, Wh -/-, Rales +/+ Cor : regular, murmur (-) Abdomen: liver not palpable Ext : oedem -/-

Lab: Hb : 11,5 g/dl , GDS 108HT : 33 % Ur/Cr : 60/ 3,5Leukocyte : 3500 /mm3, Thromb :174.000 /mm3

WD : Septic cb BronkopneumoniCKD stg V cb Nefrosklerosis Hipertension on regular HD

Therapy:Rest/O2 2l/IVFD NaCl 0,9% 8 hours/kolfInj Cefoperazon 1x2grCiprofloxacin inf 2x100mgInj Dexametason 3x5mgParacetamol 3x500,gAmbroxol 3xc1Yuni Nduru, Female, 34yo, HCU CC : Breathlessness since 2 days ago

Present Illness History :Breathlessness since 2 days agoCough since 2 days agoFever since 2 weeks agoNausea vomit, frequent 3-4x/dayHypertension history since 5 years agoPhysical Examination: GA: moderate, Consciousness: CMCBP: 210/120, Pulse: 108 RR: 44, Temp: 37C

Eyes : anemic+/+, icteric -/-Neck : JVP 5-2 cmH2OThorax : Lung : bronchovesiculer, Wh -/-, Rales +/+ Cor : regular, murmur (-) Abdomen: liver not palpable Ext : oedem -/-

Lab: Hb : 8,3 g/dl , HT : 25 % Ur/Cr : 84/2,5 -> TKK=22,3Leukocyte : 20.300 /mm3, Thromb :505.000 /mm3

WD : CKD stg IV cb Nefrosklerosis HipertensionCommunity Acquired Pneumonia

Therapy:Rest/RG II RP 40gr/O2 NRM 10 l 6 hoursIVFD Easprimmer 500cc/24 hoursInj Ceftriaxon 1x2grAmbroxol 3xc1Inj Lasix 1x1 ampCandesartan 1x16mgBic Nat 3x1As folat 1x5mgParacetamol 3x500Amlogrix 1x1CrossmatchPRC Transfusion Cc: cough since 15 days agoPresent illness history:Cough since 15 days agoFever since 15 days agoThe decrease of appetite few days agoDiabetic history since 3 years ago. Patient checked herself regularly and ever got oral anti diabetes. She doesnt take any diabetic medication at the moment.Rainas, female, 65 yo, FW-16 (dr. Guptaja)Physical examination:GA: moderateConsc: CMCBP: 120/80Pulse: 92RR: 24T: 37.9Weight: 50Height: 155Eye; anemic conj (-/-), icteric sclera (-/-)Heart: cardiomegali (-)Lung: bronchovesiculer, rales +/+, wh -/-Stomach: normalExtr: edema -/-Lab:Hb: 8.2Na/K/Cl: 130/4.1/105Leuco: 5000RBG: 132Ht: 24Ur/Creat: 42/1Trombo: 121000

WD:Geriatric bronchopneumoniaType II DM controlled by diet, normoweightHyponatremia cb low intakeMild anemia normocitic normochrom cb chronic diseaseTherapy:Rest/soft diet DD 1500 kkalIVFD NaCl 0.9% 8h/kolfCeftriaxone vial 1x2gr (skin test)Azythromicine 1x500mgAmbroxol syr 3xcth2NTR 2x1PCT 3x500mgCc: fever since 5 days agoPresent Illness History:Fever since 5 days agoVomit (+) since 1 day agoEpigastric pain since 1 day agoGum bleeding (+), when patient brushed her teethHeadache (+), muscle pain (+)Nurhayati Matondang, female, 25 yo, TI (dr. Guptaja)Physical examination:GA: moderateCons: CMCBP: 100/70Pulse: 98RR: 16T: 39.6Eye: anemic conj -/-Heart, lung and abd: normalExtr: edema -/-, petechie (+)Lab:Hb: 12.5Leuco: 1000Ht: 37Trombo: 35000WD:Dengue feverThy:Rest/soft dietIVFD RL 8h/kolfPCT 3x500mgLansoprazole 1x30mgDomperidone 3x10mg1. Ramli,52 years old,MW-11(dr.Arnaldo)CC : breathlessness increase since 3 days ago

Present illness history : Breathlessness increase since 3 days agoCough since 3 weeks agoFever(+)since 2 weeks ago

Physical Finding :VS/ cmc,BP:110/70 mmHg, HR: 88x/i, RR:28T: 36,70 C

Eyes : conjunctiva anemis-/-JVP: 5-2 cmH2OLung: broncovesiculer, rales(+/+), wh(-/-)Heart: Ictus palpable 1 finger lateral LMCS RIC VIAbdomen: hepar palpable 2 finger BAC,3 finger bpx,Ext: edema -/-

Lab :Hb: 17,8g/dlLeucocyte: 7300/uLHt:53% Trombocyte: 66000 uL

Na/K/Cl:120/5.1/90pH: 7.34pCO2: 68pO2: 41 HCO3-: 36.7BEecf: 10.9SO2: 78%

WD :CPC std decompensated e.c SOPTPPOK in acute excacerbationSusp Lung TB relapsHiponatremia e.c. Low intake Therapy :rest/low salt II low protein 40grIVFD drip 2 amp aminofilin in 500 cc Nacl 0.9% 12 hour/kolfFarbivent nebu/6 hourLasix 1x1amp IVcorrection Nacl 3% 12 hour/kolf(1 kolf)threeway Methylprednisolone inj 3x62.5 mg iv PCT 3x500 mg Ambroxol syr 3xcth II Inj Cefotaxime 1x2gr iv Fluid balance2.Syahrial,75 yo,HCU(dr.Arnaldo)CC : breathlessness increase since 2 days ago

Present illness history : Breathlessness increase since 2 days agoCough since 2 days ago.with sputumHistory of hypertension for 3 years.Regular control


Eyes : conjunctiva anemis-/-JVP: 5-2 cmH2OLung: broncovesiculer, rales(+/+), wh(-/-)Heart: normalAbdomen: normalExt: edema -/-

Lab :Hb: 12,3 g/dlLeucocyte: 20600/uLHt:35% Trombocyte: 297000 uL

Na/K/Cl:127/4.6/100pH: 7.36pCO2: 40pO2: 37 HCO3-: 22.6BEecf: -2.8SO2: 68%

WD :Broncopneumonia(CAP)Hypertension stg II e.c essentialAKI rifle I e.c prerenal e.c dehydration

Therapy :rest/low Low salt II/02 3 L/i IVFD Nacl 0.9% 8 hour/kolf Cefoperazon inj 1x2 gr iv Azitromicin 1x500mg Amlogrix 1x5 mg Candesartan 1x8 mg PCT 3x500 mg Ambroxol syr 3xcth I Fluid balance3.Desi Tri Novita,33 yo,HCU(dr.Arnaldo)CC : Yellow eyes since 5 days ago

Present illness history : Breathlessness increase since 3 days agodefecation like dempul is deniedMixturation like tea since 5 days agoFever(+)since 3 days agoCough(+)since 3 days ago


Eyes : conjunctiva anemis+/+,sclera icteric -/-JVP: 5-2 cmH2OLung: broncovesiculer, rales(+/+), wh(-/-)Heart: normalAbdomen: normalExt: edema -/-

Lab :Hb: 8.1g/dlLeucocyte: 32200/uLHt:23% Trombocyte: 306000 uL

Na/K/Cl:120/3.9/92SGOT/SGPT:31/30Ur/cr:177/4.5

WD :Icterus kolestatik extrahepatal e.c susp koledokolitiasisSeptic e.c BP (CAP)AKI Rifle F e.c Prerenal e.c dehydrationHiponatremia e.c low intake Therapy : rest/DH II IVFD Nacl 0.9% 6 hour/kolf Correction NaCl 3% 12 hour/kolf Sistenol 3x500 mg Curcuma 3x1 Inj.Cefoperazon 1x2 gr iv Ciprofloxacin Inf 2x100 mg Dexametason 3x5 mg Ambroxol 3xcth II Fluid balance1. Martini 49 years old,PETRI (dr.Edo)CC : Fever since 1 week ago

Present illness history : Fever since 1 week agoHeadache since 4 days ago


Eyes : conjunctiva anemis-/-JVP: 5-2 cmH2OLung: normalHeart: normalAbdomen: normalExt: edema -/-

Lab :Hb: 14g/dlLeucocyte: 6400/uLHt:40% Trombocyte: 137000 uL

WD :Malaria Vivax Therapy :

Rest/daily dietPCT 3x500 mgNTR 3x1Domperidon 3x1Darplex 1x3 tab until 3 days,and then 1x1 tabPrimakuin 1x3 continue 1x1 tab until day 14Agusril 47 years old,MW-24 (dr.Edo)CC : dizziness since 2 week ago

Present illness history : Dizziness since 2 week agoCough since 1 month agoBreathlessness since 2 weeks ago


Eyes : conjunctiva anemis-/-JVP: 5-2 cmH2OLung: broncovesiculer,Rh+/+,wh-/-Heart: normalAbdomen: normal,colonostomy scar(+)Ext: edema -/-

Lab :Hb: 11.4g/dlLeucocyte: 12900/uLHt:34% Trombocyte: 439000 uL RGB:311Ur/Cr:43/1.6

WD :DM Tipe II just be knownPost kolonostomy e.c obstruction Therapy :

Rest/DD 2100 KkalIVFD Nacl 0.9% 12 hour/kolfPCT 3x500 mgNTR 3x1Ceftriaxone inj 1x2 grMetformin 3x500 mgAfrida Purwanti, Female, 18 y.o (dr.Farah)CC : Fever since 3 weeks ago

Present Illness History:Fever since 3 weeks agoCough since 1 weeks agoLost of appetite since a week agoNausea since 1 days ago, and no vomitNo gum, skin and other bleeding

Physical Examination: GA: moderate, Consciousness: CMCBP: 110/60 Pulse: 80, RR: 22, Temp: 36,8C

Mouth : Coated tounge (-)Eyes : anemic-/-, icteric -/-Neck : JVP 5-2 cmH2OThorax : Lung : bronchovesiculer, Wh -/-, Rales +/+ Cor : regular, murmur (-) Abdomen: liver not palpable Ext : oedem -/-

Lab: Hb : 11,7 g/dl , HT : 33%Leukocyte : 5400/mm3, Trombocite : 178.000/mm3

WD : Bronchopneumonia (CAP)

Therapy: Rest/ Daily DietIVFD NaCl 0,9% 8 hours/kolfAmbroxol 3xc1Paracetamol 3x500mg

1. Musniwati, female, 55 YO, FW 17CC: Vomit increased since 2 days ago

Present illness historyVomit increased since 2 days ago, vomit 2-3 times per dayHistory of gastric disease since 4 years agoEpigastric pain since 2 days agoFever (+), cough (+)History of get TB drug (+)

Physical findingVS/ cmc, BP:130/80 mmHg, HR: 98x/i, RR: 22x/i, T: 35,80 C

Eyes : anemic -/-, icteric -/-Chest: bronchovesiculer, rales +/+Abdomen: Epigastric pain (+), Liver and spleen not palpableExt: edema(-/-)

LabHb: 12,2 g/dlLeucocyte: 10.200 uLHt: 36%Trombocyte:376.000 uLNa/K/Cl : 142 / 3,7 / 106 mmol/LRBG : 130 mg/dlUr/cr : 21/1,2

Expertise of Ro thorax : Lung TB duplexWDChronic GastritisLung TB relapsBronchopneumonia duplex

DD : Peptic ulcerTh/ rest/gastric diet IIIVFD NaCl 0,9% 8 hours/kolfInj Ceftriaxon 1 x 2 gr IVParacetamol 3 x 500 mgAmbroxol 3 x cthIIDomperidon 3 x 1 tabSucralfat syr 3 x cth II

2. Noveri Mairizal, male, 31 YO, MW 17CC: Cough increased since 4 days ago

Present illness history:Cough increased since 4 days ago, cough has been suffered since 1 month agoFever (+)Sweating in the night (+)Breathlessness (-)

Physical FindingVS/ cmc,BP:120/80 mmHg, HR: 76x/i, RR: 24x/i, T: 36,70 CEyes : anemi -/-, icteric -/-Chest: bronchovesiculer, rales +/+ at apex and basal of the lungAbdomen: supel, liver and spleen not palpableExt: edem -/-

LabHb:14,2g/dlLeucocyte: 12.400/uLHt:41% Trombocyte: 182.000 uL WD:Bronchopneumonia duplexLung TB

Th/Rest / Daily diet high callory high proteinInj Cefoperazone 2 x 1 gr IVPCT 3 x 500 mgAmbroxol syr 3 x cth IINTR 2 x 1 tab

Duty Report March

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