DUTY REPORT

1st June 2016

PPDS on duty
Coass on duty

: dr. Rizki Febriani Putri

: Chaerunisa and Vatiana

PATIENTS RECAPITULATION
3rd floor: 4th floor: Mr.M, 39 y.o, HIV, CAP dd TB,
GEA
5th floor: Mrs. N, 37y.o, stroke, abdominal
pain
Mrs.S, 40y.o, icteric obstruction
6th floor: Mr.Y, 41y.o, DHF
Mr. A, 29y.o, GEA

PATIENTS IDENTITY
Name
: M
Sex
: Male
Age
: 39 years old
Marital Status : Single
Address
: Galur, Jakarta
Medical Record : 832659

ANAMNESIS
Autoanamnesa on 1/06/16
Chief Complain: patient came with
weakness for 2 weeks before admission

CURRENT ILLNESS
Patient with weakness for 5 month, getting
worse 2 weeks before admission. He
feels the weakness all over the body. He
also complaint diarrhea for 5 months with
brown feaces and no blood. He has fever,
cough with white sputum for over 3
weeks without blood. Short of breath (-),
chest pain (-), headache (+), nausea (+),
vomit (+), decreasing of appetite,
decreasing of body weight from 56kg to
39kg, night sweating (-).

CURRENT ILLNESS
He
has
been
diagnosed
with
immunocompromised, had been treating for HIV
for 3 months and stopped because he feels itchy
on his body. His HIV drug was given 1 tab/day.
Patient has history of sexual activity with men and
women with condom, but sometimes he doesnt
use condom. Oral sex (+), anal sex (+). Patient
has no tatoo, no drug, no alcohol, no smoke.

RPD: history of same illnes (-), icterus (-), seizure

(-), hypertension (-), DM (-), asthma (-), allergy (-)
RPK: HT (-), Dm (-), asthma (-), allergy (-)
Medication history: ARV for 3 months

VITAL SIGNS

General State
:
Consciousness
Blood Pressure
Pulse
:
Respiratory Rate
Temperature
Body Weight
Body Height
BMI
:

PHYSICAL
EXAMINATION
Mild Sickness
: Compos Mentis
: 90/60 mmHg
115 x/minute, regular
: 18 x/minute
: 38 oC
: 39 kg
: 155 cm
16,25 (underweight)

PHYSICAL
EXAMINATION
General Examination

Head
: Normocephal
Eye
: pale conjunctiva (+/+), icteric sclera (-/-)
Ears
: normotia, discharge (-)
Nose
: septum deviation (-), discharge (-)
Mouth : dried mucose(-), oral candidiasis (-)
Neck
: lymph nodes enlargement (-)

Physical examination
Neck : JVP 5-2 cm H2O
Lungs
I : symmetric static and dynamic
P : fremitus same in both lungs
P : sonor left and right
A: vesiculer, rhonchi +/-, wh -/-

Physical examination
Heart
I : Ictus cordis at the left linea mid
clavicula, 5 th intercostae,
P : Ictus cordis palpable 2 fingers at the
medial side of left linea mid clavicula, theres
no thrill, no dilated heart border.
A : first and secong heart sound are normal,
murmur -, gallop -

Physical examination
abdominal I : flat, symmetric
P : tenderness on abdomen, no liver or
spleen enlargement, skin turgor (+)
P: timpani
A: bowel sound
Extremity : warm, with no edema
Lymph nodes : no enlargement

DIAGNOSTIC PLANS
LABORATORIUM
RESULT

NORMAL RANGE

Hb

13.4

13 - 18 g/dl

Ht

37

40 52 %

Erythrocyte

4.7

4.3 - 6.0 mil /ul

Leukocyte

11420

4800 - 10800/ul

Thrombocyte

345000

150000 - 400000/ul

MCV

79

80 96 fL

MCH

29

27 - 32 pg

MCHC

36

32 36 g/dL

Hematologi rutin:

RESULT

NORMAL RANGE

SGOT

42

< 35

SGPT

16

< 40

Ureum

18

20 50 mg/dL

Creatinine

0.7

0.5 1.5 mg/dL

RBS

197

<140 mg/dL

Natrium

120

135 147 mmol/L

Kalium

2.8

3.5 5 mmol/L

Cloride

73

95 105 mmol/L

RESUME
Patient, male 39 with weakness for 5 months, getting worse 2 weeks before
admission. weakness all over the body. Pasient has diarrhea for 5 month
brown feaces, fever, cough with white sputum for over 3 weeks, headache
(+), nausea (+), vomit (+), decreasing appetit, decreasing of body weight from
56kg to 39kg. Immunocompromized with HIV treatment for 3 months, stop
because he feel itchy on his body. Patient has history of sexual activity with
men and women sometimes use condom sometimes not. Oral sex (+), anal
sex (+).
From the physical examination, the blood pressure was 90/60 mmHg,
temperature 38oC, BMI 16,25 (underweight), pale congjutiva (+/+), and
rhonchi (+/-), tenderness (+) on abdomen.
From the laboratory findings, there were found

PROBLEMS LIST
CAP dd TB paru
GEA mild dehidration with Daldiyono
Score 2
SIDA treatment with ARV

ASSESSMENT For Working

Diagnose
CAP dd TB
Anamnesis: fever, cough with white sputum over 3 weeks,
decreasing of body weight.
Physical examination: rhonchi (+/-)
Lab finding: ()
Plan:
Diagnostic: sputum BTA, kultur, rontgen
Therapy: IVFD RL 500cc/8 hour
paracetamol 3x500mg po

ASSESSMENT For
Working Diagnose
GEA mild dehidration with Daldiyono Score 2
Anamnesis: diarrhea, vomit, nausea
Physical examination: tenderness (+) on abdomen
Lab finding:
Plan:
Diagnostic: FL, darah samar tinja, elektrolit, ur, cr
Therapy: new diatabs 2 tab/diarrhea. Max 12tab/day

ASSESSMENT For
Working Diagnose
SIDA with ARV history treatment
Anamnesis: weakness for 5 months getting worse 2 weeks before
admission, headache, decresing appetite, decreasing of body
weight, ARV treatment for 3 months, free sex (+).
Physical examination: pale conjungtiva
Lab finding:
Plan:
Diagnostic: CD4, SGOT SGPT, HbsAg, anti HCV
Therapy: cotrimoxazole 2x960mg

PROGNOSIS
Qua ad vitam
: dubia
Qua ad functionam : dubia
Qua ad sanationam : dubia

THANK YOU