Duty Report,

Wednesday March
13th 2013
Dr. Arnaldo Eka Putra
Dr. Sri Anggraeni
Dr. Rizka Rosalinda
Dr. Edo Yudistira
Dr. Farah Soraya
Dr. Guptaja Kusumah N

Weni Wijayanti, female, 30 yo,

HCU (dr. Arnaldo E P)
Cc: breathlessness since 1 week ago
Present Illness History:

Breathlessness since 1 week ago

Enlargement of the stomach since 2 months ago
Fatigue (+)
The decrease of appetite (+)
Patient has history of looking blueish when she
cried

Physical Examination:
GA: moderate
Consc: CMC
BP: 100/60
Pulse: 108x
RR: 38x
T: 36,8

Eye: anemic conj (+/+), icteric sclera (-/-)

Neck: JVP 5+2cmH2O
Pulmo: vesiculer, rales (-/-)
Cor: ictus was palpable 1 finger lateral from
ICR VI, M1>M2, P2<A2
Abd: undulation (+), liver and spleen were
unpalpable
Extr: edema (+/+)

Lab:
Hb: 9.5
Leuco: 9100
Ht: 31
Trombo: 330000
Na/K/Cl: 134/4.1/106
RBG: 91
Ur/Creat: 10/0.7

WD:
CHF fc III LVH-RVH sinus tachycardia cb Congenital
Heart Disease
Cirrhosis Cardiac
Mild anemia normocitic normochrom cb chronic
disease

Therapy:
Rest/liver diet II heart diet II
IVFD NaCl 0.9% 12h/kolf
Lasix amp 1x1
Curcuma 3x1
Ramipril 1x2.5mg
Dulcolax 1x2
Catheter fluid balance

Lukman Hadi, male, 27 yo (dr

Arnaldo)
Cc: vomit since 4 hours ago
Present Illness History:

Vomit since 4 hours ago

Patient drank 1/3 of sunlight before
Breathlessness (-)
Fever (-)

Physical examination:
GA: moderate
Consc: CM not cooperative
BP: 110/60
Pulse: 74
RR: 22
T: 36.5

Eye: anemic conj (-/-), icteric sclera (-/-)

Cor, pulmo and abd: normal
Back: CVA pain -/ Extr: edema (-/-)

Lab:
Hb: 13
pH: 7.32
Leuco: 3400
pO2: 107
Ht: 38
pCO2: 21
Trombo: 143000
HCO3-: 10.8
Na/K/Cl: 137/3.6/106 SO2: 98
RBG: 79
Ur/Creat: 18/1.2

WD:
Intoxication

Therapy:
Rest/flow NGT fasting 8 hours -> gastric diet
I
IVFD NaCl 0.9% 8h/kolf
Ozid vial 1x1
Sucralfat syr 3xcth1
Domperidone 3x10mg
Fluid balance

Geno Yuliasri, male, 16 yo, MW11 (dr. Arnaldo)

Cc: breathlessness since 3 days ago
Present Illness History:
Breathlessness since 3 days ago
Cough since 1 week ago
Vomit (+)
Patient has been known having heart
disease since 2 months ago

Physical examination:
GA: moderate
Consc: CMC
BP: 110/70
Pulse: 98
RR: 26
T: 37.2

Eye: anemic conj (-/-), icteric sclera (-/-)

Neck: JVP 5+2cmH2O
Heart: ictus was palpable 1 finger lateral
from ICR VI, murmur (-), gallop (-)
Lung: bronchovesiculer, rales +/+, wh -/ Stomach: liver and spleen were unpalpable
Extr: edema -/

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

WD:
Bronchopneumonia (CAP)
Dispepsia syndrome, dismotility type
CFH fc II LVH-RVH sinus rhythm cb
Rheumatic Heart Disease
Hyponatremia cb vomit

Therapy:
Rest/heart diet II gastric diet II
IVFD NaCl 0.9% 12h/kolf
Ceftriaxone vial 1x2gr (skin test)
PCT 3x500mg
Ambroxol syr 3xcth2
Ozid vial 1x40mg
Sucralfat syr 3xcth2
Domperidone 3x10mg
Furosemide 1x40mg
Cardace 1x2.5mg
Bisoprolol 1x2.5mg
Spirinolacton 1x12.5mg
Erithromicine 2x250mg
Fluid balance

Ceftriaxone vial 1x2gr (skin test)

Ciprofloxacine drip 2x100mg
Metronidazole drip 3x500mg
PCT 500mg 3x1
Amlodipine 5mg 1x1
Candesartan 8mg 1x1
Lasix amp 1x1
Folic acid 5mg 1x1
Bicnat 500mg 3x1
Catheter fluid balance
Redressing twice a day

Toroi Manga, Male, 55 y.o,

MW
CC: 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
hospitalized
Fever since 2 weeks ago
Nausea and vomit (-)

Physical Examination:
GA: moderate,
Consciousness: CMC
BP: 140/80,
Pulse: 88,
RR: 32,
Temp: 36,8C
Eyes
: anemic-/-, icteric -/Neck
: JVP 5-2 cmH2O
Thorax : 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 Pneumonia
Susp. Varicela
IO with Lung TB duplex
Therapy:
Rest/Soft Diet
IVFD NaCl 0,9% 8 hours/kolf
Inj Ceftriaxon 1x2gr iv
Ambroxol 3x1
Paracetamol 3x500mg

Amrizal, Male, 59 y.o, HCU

CC : Fever since 2 days ago
Present Illness History:
Fever since 2 days ago.
Cough since 1 week ago
Breathlessness (-)
Patient has been known got kidney disease
since 9 months ago and got Hemodialisa
regularly
Hypertension history since 5 years ago

Physical Examination:
GA: moderate,
Consciousness: CMC
BP: 130/80,
Pulse: 107,
RR: 22,
Temp: 38,2C
Eyes
: anemic-/-, icteric -/Neck
: JVP 5-2 cmH2O
Thorax : Lung : bronchovesiculer, Wh -/-, Rales +/+
Cor : regular, murmur (-)
Abdomen: liver not palpable
Ext
: oedem -/Lab:
Hb : 11,5
g/dl ,
GDS 108
HT : 33 %
Ur/Cr : 60/ 3,5
Leukocyte : 3500 /mm3,
Thromb :174.000
/mm3

WD :
Septic cb Bronkopneumoni
CKD stg V cb Nefrosklerosis Hipertension on
regular HD
Therapy:
Rest/O2 2l/
IVFD NaCl 0,9% 8 hours/kolf
Inj Cefoperazon 1x2gr
Ciprofloxacin inf 2x100mg
Inj Dexametason 3x5mg
Paracetamol 3x500,g
Ambroxol 3xc1

Yuni Nduru, Female, 34yo, HCU

CC : Breathlessness since 2 days ago
Present Illness History :
Breathlessness since 2 days ago
Cough since 2 days ago
Fever since 2 weeks ago
Nausea vomit, frequent 3-4x/day
Hypertension history since 5 years ago

Physical Examination:
GA: moderate,
Consciousness: CMC
BP: 210/120,
Pulse: 108
RR: 44,
Temp: 37C
Eyes
: anemic+/+, icteric -/Neck
: JVP 5-2 cmH2O
Thorax : 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=22,3
Leukocyte : 20.300 /mm3,
Thromb :505.000
/mm3

WD :
CKD stg IV cb Nefrosklerosis
Hipertension
Community Acquired Pneumonia

Therapy:
Rest/RG II RP 40gr/O2 NRM 10 l 6 hours
IVFD Easprimmer 500cc/24 hours
Inj Ceftriaxon 1x2gr
Ambroxol 3xc1
Inj Lasix 1x1 amp
Candesartan 1x16mg
Bic Nat 3x1
As folat 1x5mg
Paracetamol 3x500
Amlogrix 1x1
Crossmatch
PRC Transfusion

Rainas, female, 65 yo, FW-16

(dr. Guptaja)
Cc: cough since 15 days ago
Present illness history:

Cough since 15 days ago

Fever since 15 days ago
The decrease of appetite few days ago
Diabetic history since 3 years ago. Patient
checked herself regularly and ever got oral anti
diabetes. She doesnt take any diabetic
medication at the moment.

Physical examination:
GA: moderate
Consc: CMC
BP: 120/80
Pulse: 92
RR: 24
T: 37.9
Weight: 50
Height: 155

Eye; anemic conj (-/-), icteric sclera (-/-)

Heart: cardiomegali (-)
Lung: bronchovesiculer, rales +/+, wh -/ Stomach: normal
Extr: edema -/

Lab:
Hb: 8.2
Na/K/Cl: 130/4.1/105
Leuco: 5000
RBG: 132
Ht: 24
Ur/Creat: 42/1
Trombo: 121000

WD:
Geriatric bronchopneumonia
Type II DM controlled by diet, normoweight
Hyponatremia cb low intake
Mild anemia normocitic normochrom cb
chronic disease

Therapy:
Rest/soft diet DD 1500 kkal
IVFD NaCl 0.9% 8h/kolf
Ceftriaxone vial 1x2gr (skin test)
Azythromicine 1x500mg
Ambroxol syr 3xcth2
NTR 2x1
PCT 3x500mg

Nurhayati Matondang, female,

25 yo, TI (dr. Guptaja)
Cc: fever since 5 days ago
Present Illness History:

Fever since 5 days ago

Vomit (+) since 1 day ago
Epigastric pain since 1 day ago
Gum bleeding (+), when patient brushed her
teeth
Headache (+), muscle pain (+)

Physical examination:
GA: moderate
Cons: CMC
BP: 100/70
Pulse: 98
RR: 16
T: 39.6

Eye: anemic conj -/ Heart, lung and abd: normal

Extr: edema -/-, petechie (+)

Lab:
Hb: 12.5
Leuco: 1000
Ht: 37
Trombo: 35000

WD:
Dengue fever

Thy:
Rest/soft diet
IVFD RL 8h/kolf
PCT 3x500mg
Lansoprazole 1x30mg
Domperidone 3x10mg

1. Ramli,52 years old,MW-11(dr.Arnaldo)

CC : breathlessness increase since 3 days ago
Present illness history :
Breathlessness increase since 3 days ago
Cough since 3 weeks ago
Fever(+)since 2 weeks ago

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

Eyes : conjunctiva anemis-/JVP: 5-2 cmH2O

Lung: broncovesiculer, rales(+/+), wh(-/-)
Heart: Ictus palpable 1 finger lateral LMCS RIC VI
Abdomen: hepar palpable 2 finger BAC,3 finger
bpx,
Ext: edema -/-

Lab :
Hb: 17,8g/dl
Ht:
53%

Leucocyte: 7300/uL
Trombocyte: 66000 uL

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

WD :
CPC std decompensated e.c SOPT
PPOK in acute excacerbation
Susp Lung TB relaps
Hiponatremia e.c. Low intake

Therapy :
rest/low salt II low protein 40gr
IVFD drip 2 amp aminofilin in 500 cc Nacl
0.9% 12 hour/kolf
Farbivent nebu/6 hour
Lasix 1x1amp IV
correction 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 balance

2.Syahrial,75 yo,HCU(dr.Arnaldo)
CC : breathlessness increase since 2 days ago
Present illness history :
Breathlessness increase since 2 days ago
Cough since 2 days ago.with sputum
History of hypertension for 3 years.Regular
control

Physical Finding :
VS/ cmc,BP:180/100 mmHg, HR: 80x/i, RR:18
T: 36,50 C

Eyes : conjunctiva anemis-/JVP: 5-2 cmH2O

Lung: broncovesiculer, rales(+/+), wh(-/-)
Heart: normal
Abdomen: normal
Ext: edema -/-

Lab :
Hb: 12,3 g/dl
Ht:
35%

Leucocyte: 20600/uL
Trombocyte: 297000 uL

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

WD :
Broncopneumonia(CAP)
Hypertension stg II e.c essential
AKI 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 balance

3.Desi Tri Novita,33 yo,HCU(dr.Arnaldo)

CC : Yellow eyes since 5 days ago
Present illness history :
Breathlessness increase since 3 days ago
defecation like dempul is denied
Mixturation like tea since 5 days ago
Fever(+)since 3 days ago
Cough(+)since 3 days ago

Physical Finding :
VS/ cmc,BP:110/80 mmHg, HR: 120x/i, RR:36
T: 36,70 C

Eyes : conjunctiva anemis+/+,sclera icteric -/JVP: 5-2 cmH2O

Lung: broncovesiculer, rales(+/+), wh(-/-)
Heart: normal
Abdomen: normal
Ext: edema -/-

Lab :
Hb: 8.1g/dl
Ht:
23%

Leucocyte: 32200/uL
Trombocyte: 306000 uL

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

WD :
Icterus kolestatik extrahepatal e.c susp
koledokolitiasis
Septic e.c BP (CAP)
AKI Rifle F e.c Prerenal e.c dehydration
Hiponatremia 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 balance

1. Martini 49 years old,PETRI (dr.Edo)

CC : Fever since 1 week ago
Present illness history :
Fever since 1 week ago
Headache since 4 days ago

Physical Finding :
VS/ cmc,BP:140/90 mmHg, HR: 84x/i, RR:24
T: 36,70 C

Eyes : conjunctiva anemis-/JVP: 5-2 cmH2O

Lung: normal
Heart: normal
Abdomen: normal
Ext: edema -/-

Lab :
Hb: 14g/dl
Ht:
40%

Leucocyte: 6400/uL
Trombocyte: 137000 uL

WD :

Malaria Vivax

Therapy :
Rest/daily diet
PCT 3x500 mg
NTR 3x1
Domperidon 3x1
Darplex 1x3 tab until 3 days,and then 1x1
tab
Primakuin 1x3 continue 1x1 tab until day 14

Agusril 47 years old,MW-24 (dr.Edo)

CC : dizziness since 2 week ago
Present illness history :
Dizziness since 2 week ago
Cough since 1 month ago
Breathlessness since 2 weeks ago

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

Eyes : conjunctiva anemis-/JVP: 5-2 cmH2O

Lung: broncovesiculer,Rh+/+,wh-/Heart: normal
Abdomen: normal,colonostomy scar(+)
Ext: edema -/-

Lab :
Hb: 11.4g/dl
Ht:
34%
RGB:311
Ur/Cr:43/1.6

Leucocyte: 12900/uL
Trombocyte: 439000 uL

WD :
DM Tipe II just be known
Post kolonostomy e.c obstruction

Therapy :
Rest/DD 2100 Kkal
IVFD Nacl 0.9% 12 hour/kolf
PCT 3x500 mg
NTR 3x1
Ceftriaxone inj 1x2 gr
Metformin 3x500 mg

Afrida Purwanti, Female, 18 y.o

(dr.Farah)
CC : Fever since 3 weeks ago
Present Illness History:
Fever since 3 weeks ago
Cough since 1 weeks ago
Lost of appetite since a week ago
Nausea since 1 days ago, and no vomit
No gum, skin and other bleeding

Physical Examination:
GA: moderate,
Consciousness: CMC
BP: 110/60
Pulse: 80,
RR: 22,
Temp: 36,8C
Mouth
Eyes
Neck
Thorax

: Coated tounge (-)

: anemic-/-, icteric -/: JVP 5-2 cmH2O
: 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 Diet
IVFD NaCl 0,9% 8 hours/kolf
Ambroxol 3xc1
Paracetamol 3x500mg

1. Musniwati, female, 55 YO, FW 17

CC: Vomit increased since 2 days ago
Present illness history
Vomit increased since 2 days ago, vomit 2-3
times per day
History of gastric disease since 4 years ago
Epigastric pain since 2 days ago
Fever (+), cough (+)
History of get TB drug (+)

Physical finding
VS/ 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 palpable
Ext: edema(-/-)

Lab
Hb: 12,2 g/dl
Leucocyte: 10.200 uL
Ht: 36%
Trombocyte:376.000 uL
Na/K/Cl : 142 / 3,7 / 106 mmol/L
RBG : 130 mg/dl
Ur/cr : 21/1,2
Expertise of Ro thorax : Lung TB duplex

WD
Chronic Gastritis
Lung TB relaps
Bronchopneumonia duplex

DD : Peptic ulcer

Th/ rest/gastric diet II

IVFD NaCl 0,9% 8 hours/kolf
Inj Ceftriaxon 1 x 2 gr IV
Paracetamol 3 x 500 mg
Ambroxol 3 x cthII
Domperidon 3 x 1 tab
Sucralfat syr 3 x cth II

2. Noveri Mairizal, male, 31 YO, MW 17

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

Physical Finding
VS/ cmc,BP:120/80 mmHg, HR: 76x/i, RR: 24x/i,
T: 36,70 C
Eyes : anemi -/-, icteric -/ Chest: bronchovesiculer, rales +/+ at apex and
basal of the lung
Abdomen: supel, liver and spleen not palpable
Ext: edem -/Lab
Hb: 14,2g/dl
Leucocyte: 12.400/uL
Ht:
41%
Trombocyte: 182.000 uL

WD:
Bronchopneumonia duplex
Lung TB

Th/

Rest / Daily diet high callory high protein

Inj Cefoperazone 2 x 1 gr IV
PCT 3 x 500 mg
Ambroxol syr 3 x cth II
NTR 2 x 1 tab