Duty Report, June 12th Complete

7/28/2019 Duty Report, June 12th Complete

1/94

DUTYREPORTJUNE 26TH 2013


2/94

MARDIAS ANJAS,MALE, 65 YO , MW16

Cc : Epigastric pain since 4 days ago

Present illness history :

Epigastric pain since 4 days ago,no refer, Heartburn since 4 days ago

Nausea (+), vomit (+) since 2 days ago, twice, 1

spoonfull, consist of food and water consumed

Hip cup since 2 days ago

Decreased of apetite and no drink since 1 days ago

Volume of Mixturation was decreased since 1 day

ago,Volume

Fever (-)


3/94

- Cough (-)

- Defecation Normal

- Patient has been hospitalize 1 month ago with diagnose

Broncopneumonia and Hip cup

Physical examination :

Consc : CMC

BP : 120/80 mmHg

HR : 88x/

RR : 20x/T : 37 C

Eye : Conjuctiva not anemic,sclera not icterus

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

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

Abdomen: Liverand spleen werent palpable, tenderness on epigatric, bowel

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

Pathology reflex:(-)/(-) Normal

Edem (-)/(-)


4/94

Laboratorium

Hb : 13,1 gr/dl

Leu : 7700/mm3

Ht : 39%

Trombosit : 216.000/mm3

Na : 138 mmol/L

K : 3,6 mmol/L

Cl : 109 mmol/L

GDS : 105 mg/dlUreum : 31 mg/dl

Creatinin : 1,6 mg/dl

Protein Urin : ( )


5/94

WD :

Gastroesophageal Reflux Disease

DD/ Peptic Ulcer

AKI rifle R cb pre renal cb dehydration

Th :

Rest/ Gastric diet II IVFD NaCl 0,9 % 8 hours/ kolf

Inj.Omeprazole 1x1 (IV)

Domperidon 3x10 mg

Sukralfat Syr 3xCth II

Fluid Balance


6/94

Suggestion

Urinalyse

Ureum, creatinin evaluation/3 days

Gastroscopy


7/94

1.Herawati, 63 yo, female, FW 15 (dr.Riko)

Cc: Nausea and Vomit since 5 days ago

Present illness history:

- Nausea and vomit since 5 days ago,frequency 3

time/days,volume 1 glass/x vomit

- Epigastrium pain since 5 days ago

- Decrease of apetite since 5 days ago

- Fever since 3 days ago, continue,no sweat,no tremble

- Pain of joint and muscle since 3 days ago

- Headache since 3 days


8/94

- Bleeding of Gum was denied

- Defecation and mixturation usuall

- History of DM from since 15 years ago,reguler control,consumpt insulin

- History of Hipertension from since 15 years ago,reguler

control, consumpt drug (amlodipin 1x 5 mg,candesartan

1x16mg)

Physical finding

Sensorium:CMC

VS: Blood Presure:110/80 mmHg

Heart Rate:87x/i, Respiratory Rate:20x/i,Temperature:370 C

Ideal weight Body = 47,2 kg

Body Mass Index =21,6 kg/mm2


9/94

- Skin : Rumple Leed (+), flushing (-)

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

- Lung : vesicular, rales (-/-), whezing (-/-)

- Heart: reguler, murmur (-)

- Abdoment : Liver and spleen unpapable , pain on

epigastrium

- Extremity : Fisiology reflex :(+)/(+) Normal

Pathology reflex:(-)/(-) Normal

right left

Sensibiltas + Normal + Normal

Pulsation a.dorsalis pedis + Normal + NormalPulsation a.tibialis posterior + Normal + Normal

Pulsation a.poplitea + Normal + Normal

Edem (-)/(-)


10/94

Laboratorium

Hemoglobin:11,5 gr/dl

Leucocyte: 4300/mm3

Hemotocrit : 35%

Platelet: 103.ooo/mm3

GDS: 201gr/dlGDS 168 gr/dl

Sodium : 126 mmol/dl

Clorida: 97 mmol/l

Kalium: 4 mmol/l

Ur eum : 48 mg/dl

Creatinin: 2 mg/dl

WD A t G t iti


11/94

WD : - Acute Gastritis

DD/ Fungsional dispepsia

- Dengue Fever

DD/idiophatic trobocitopenia purpura

- Type 2 DM controlled insulin normoweight- Stage II hipertension cb essensial

- AKI RIFLE R cb prerenal cb dehydration

- Hyponatermia cb vomit

Th/: - Rest/Gastric Diet III/Low salt Diet III/Diabetic Diet1700 kkal

- IVFD NaCl 0,9 % 6hours/kolf

- Lansoprazole 1x30 mg

- Domperidon 3 x 10 mg

- Amlodipin 1x5 mg- Candesartan 1x 16 mg


12/94

- Paracetamol 3x500mg- sukralfat syrup 3xcthII

- Novorapid 3x 6 IU- Levemir 1x10 IU

- Fluid Balance

Plan/

Check Hb,Ht,Platelet/24 hoursRenal function test,liver function test

Lipid profile

Check IgG,IgM antidengue

Check Ureum,creatinin 1time/daysGastroscopy

Opthalmology consultation

Nutrition consultation


13/94

Itoloni Gulo , male,21 yo, hostalized with : (dr.RINI)

Chief complain : Fever since 5 days ago.

Present illness :

- Fever (+)

- Headache (+)

- Jointpain (+)

- Epigastric pain (+)

- Vomite (+)

-Nausea (+) Past illness history :

-History of malaria (-)

- History of hepatitis (-)

Family illness history:

None of the family member get this disease.

Social /occupational/ habituation / psichiatric :

Patient is a student


14/94

Phisical Examination

1.Vital sign

- General appearence: moderate

- Level of conciousness : cmc

- BP : 110/70 mmHg

- Pulse rate : 75 x/minutes

- RR : 20 x / minutes

- body temperature : 37,9C

2.Skin : Flushing (+)

3.Eyes : conjunctiva anemic (-),sclera icteric H20

4.Neck : JVP 5 2 cmH20.

Regional lymh node : none enlargement.

Tyroid gland : none enlargement.


15/94

5. Chest

Lung :

inspection simetris

Palpation fremitus normal

percution sonor

Auscultation Breath sound vesicular normal,rales -/- ,

6. Heart , Inspection: Ictucordis anvisible

Palpation : ictus cordis palpable 1 finger medial LMCS RIC V,

Thrill (-)

Percution : Heart border Left : 1 finger medial LMCS RIC V,

Right: right sternalis line

upper ; intercostal line II

Auscultation : regular rhythm,M1>M2 P2


16/94

7. Abdominal : inspection: Not enlargement

Palpation : Liver and spleen not palpable.

Percution : thympany

auscultation : bowel sound (+) N

8.Back : CVA pain (-)

9. Extremitas : -Physiological reflex (+)

- Pathological reflex()

- Soft sensibility (+)- Rough sensibility (+)

- Oedem (-)

Laboratorium Finding:

a.Blood routine : Hb = 14 g/dl

Ht = 42,1%

leu = 1600/mm3

Thr =77.000/mm3


17/94

WD : - Dengue fever

- Suspect malaria

DD : - ITP

THY : - Rest / Gastric diet II

- IVFD Ringer lactat 8 hour/kolf

- lansoprazol 1x1 tab

- Paracetamol 3 x 500 mg

- Domperidone 3 x 1 tab.


18/94

Mawarni, female,54 yo, hostalized with : (dr.Yoga)

Chief complain : Fatigue since 1 week ago

Present illness :

- Fatigue increase since 1 week ago

- Patient has been known as diabetes since 6 years

ago

- Fever since 3 days ago

- Cough since ys ago3 day ago

- No breathlesness


19/94

Phisical Examination

1.Vital sign

- General appearence: moderate

- Level of conciousness : cmc

- BP : 110/70 mmHg

- Pulse rate : 84 x/minutes

- RR : 20 x / minutes

- body temperature : 37,2C

2.Skin : Normal

3.Eyes : conjunctiva not anemic, sclera not icteric

4.Neck : JVP 5 2 cmH20.

Regional lymh node : none enlargement.

Tyroid gland : none enlargement.


20/94

5. Chest

Lung :

inspection simetris right and left

Palpation fremitus normal

percution sonor

Auscultation Breath sound bronchovesicular,rales +/+ in both

of lung , wh -/-

6. Heart , Inspection: Ictucordis anvisible

Palpation : ictus cordis palpable 1 finger medial LMCS RIC V,

Thrill (-)

Percution : Heart border Left : 1 finger medial LMCS RIC V,

Right: right sternalis lineupper ; intercostal line II

Auscultation : regular rhythm,M1>M2 P2


21/94

7. Abdominal : inspection: Not enlargement

Palpation : Liver and spleen not palpable.

Percution : thympany

auscultation : bowel sound (+) N

8.Back : CVA pain (-)

9. Extremitas : -Physiological reflex (+)

- Pathological reflex()

- Soft sensibility (+)

- Rough sensibility (+)

- Oedem (-)

Laboratorium Finding:

a. Hb = 13,3 g/dl

Ht = 41%Leu = 11400/mm3

Thr =384.000/mm3

BG = 478 mg/dl

Keton = (-)


22/94

WD : - Type 2 DM uncontrolled normoweight

- Bronchopneumonia duplex (CAP)

THY : - Rest / DD 1900 kkal

- Inj. Ceftriaxone 1 x 2 gr (iv)

- Inj. Novorapid 3 x 10 unit

- Ambroxol syrup 3 x cth II

- NTR 3 x 1 tab


23/94

RINI, 37 YO,FEMALE, HCU

Cc : black mixturation since 3 days ago


Black mixturation since 3 days ago, pain whenmixturation (-)

Patient has been curretaged a momment before

admission

Pale since the last 3 days Fatigue since 3 days ago

Fever (-), cough (-), breathlessness (-)

Black stool (-)


24/94


Consc : CMC

BP : 110/60 mmHg

HR : 122x/RR : 28x/

T : 36,5 C

Eye : anemic (+)

Lung : fremitus was normal, vesiculer, rales (-/-)

Heart : ictus was palpable 1 finger medial of LMCS

RIC V


25/94

abdomen :

Inspection : no enlargement

Palpation : liver and spleen werent palpable

Percussion : tympaniAuscultation : bowel sound (+) N

Extremities :

Oedem (-/-)


26/94

Laboratorium

Hb : 2,6 gr/dl

Leu : 3040/mm3

Ht : 7%


Na : 140 mmol/L

K : 3,8mmol/L

GDS : 127 mg/dl

Ureum : 57 mg/dl



27/94

WD :

Severe anemia normocytic normochrome cb acute

bleeding

SIRS

Complete abortion


28/94

Th ;

rest/ soft diet/ O2 3 L/I

IVFD NaCl 0,9 % 8 hrs/kolf

ceftriaxon 1x 2gAmbroxol 3x1c

PRC transfussion untill Hb>7 g%

Fluid balance


29/94

P :

blood culture

Urine cultur

Sputum culture BMP

Obtetrics consultation


30/94

KARTI, FEMALE, 38 YO, FW 19

Cc : swelling at the left neck since 20 days ago


Swelling at the left neck since 20 days ago Fever (+),

Swelling of both palpebra since 20 days ago

Decreased of appetite to eat since 20 days ago

Nausea (-), vomit (-)

Mixturation was no complain

Black stool (-)


31/94


General appearance : moderate

Consc : CMC

BP : 110/60 mmHgHR : 122x/

RR : 28x/

T : 36,5 C

Eye : conjunctiva anemic (+), icterics of sclera (-)

Neck : JVP 5-2 mmHg


32/94

Lung :

Inspection : simetric

Palpation : fremitus decreased in sinistra

Percussion : dullness

Auscultation: vesiculer, rales (-/-)

Heart :

inspection : ictus invisible

Palpation : ictus was palpable 2 finger medial LMCS Percussion : heart border : left ; 2 finger medial of

LMCS, right : LSD

Auscultation : reguler rhythm


33/94

abdomen :



Percussion : shifting dullness (+)Auscultation : bowel sound (+) N

Extremities :oedem (+/+)


34/94

Laboratorium

Hb : 9,7 gr/dl

Leu : 3900/mm3

Ht : 29%Trombosit : 53.000/mm3

MCH : 28

MCV : 83

MCHC : 33,7

Na : 136 mmol/dlK : 2,9 mmol/dl

Ureum : 43 mg/dl



35/94

Blood gass analyze :

pH : 7,49

pCO2 : 35 pO2 : 61

HCO3- : 25,9

Beecf : -2,6

SO2 : 92%


36/94

WD :

Superior Vena cave syndrome

Septic cb limphadenitis TB

Conjunctivitis OD Pansitopenia cbHypoplasia anemia


37/94

Th :

Rest / O2 2 liter/ ML TKTP

IVFD nacl 0,9 % 6 hours /kolf

Ceftriaxon 1x2 mg Ciprofloxacin inf 2x200

Furosemid 1x20 mg

Transfusi albumin 20% 100 c

KSR 1x1


38/94

P :

rontgen thorak

BAJAH


39/94

M. SYAFII, MALE, 75 YO, HCU

Cc : reddish mixturation since 2 days ago

Present illness history;

Reddish mixturation since 2 days ago Fever (+)

History of haemodyalize (+)


40/94



Consc : CMC

BP : 110/60 mmHgHR : 108x/

RR : 36x/

T : 36,8 C

Eye : conjunctiva anemic (-), icterics of sclera (-)

Neck : JVP 5-2 mmHg


41/94

Lung :


Palpation : fremitus normal

Percussion : sonor


Heart :

inspection : ictus was invisible

Palpation : ictus was palpable 1 finger medial LMCS Percussion: heart border : left ; 1 finger medial of LMCS,

right : LSD



42/94

abdomen :



Percussion : shifting dullness (+)Auscultation : bowel sound (+) N

Extremities :

Oedem (-/-)


43/94

Laboratorium :

Hb : 9,6 gr/dl

Leu : 18.500/mm3

Ht : 30%


Na : 130 mmol/L

K : 3,5mmol/L

GDS : 112 mg/dl

Ureum : 82 mg/dl

Creatinin : 3,6mg/dl


44/94

WD :

Uroseptis

AKI rifle F cb prerenal

Mild anemia normocytic normochrome cb acutebleeding


45/94

Th :

Rest/ O2 2 l/i/ soft diet

IVFD NACL 0,9 % 6 hrs/ kolf

Ceftriaxon 1x2 gr Paractamol 4x500 mg

Fluid balance


46/94

P ;

urine culture

Rontgen thorak

BMP Renal usg


47/94

YUNIUS, 73 YO , MALE, MW 11

Cc : black vomit since 12 hours ago


Black vomit since 12 hrs ago, no fresh blood Fever (-)

Caugh (+)

History of consuming OAT (+) for 6 month

Decrease of appetite to eat no complain of mixturation

No black stool


48/94



Consc : CMC

BP : 120/70 mmHgHR : 112x/

RR : 24x/

T : 36,3 C

Eye : conjunctiva anemic (-), icterics of sclera (-)Neck : JVP 5-2 mmHg


49/94

Lung :



Percussion : sonor

Auscultation: bronchovesiculer, rales (+/+)

Heart :

inspection : ictus was invisible

Palpation : ictus was palpable 1 finger medial LMCS Percussion: heart border : left ; 1 finger medial of LMCS,

right : LSD



50/94

abdomen :




Extremities :

Oedem (-/-)


51/94

Laboratorium :

Hb : 10,9 gr/dl

Leu : 17.500/mm3

Ht : 33%


Na : 111 mmol/L

K : 4,9mmol/L

GDS : 194 mg/dl

Ureum : 51 mg/dl

Creatinin : 1,2mg/dl


52/94


pH : 7,54

pCO2 : 24 pO2 : 128

HCO3- : 20,5

Beecf : -2,0

SO2 : 99%


53/94

WD :

Hematemesis cb peptic ulcer

Hyponatremia cb low intake

Duplex Bronchopneumonia


54/94


55/94

P ;

urine culture

Renal USG

S 56 11


56/94

SYAFRIZAL ,56 YO, MALEMW 11

Cc : breathlessness since 2 days ago


Breathlessness since 2 days ago due to activity History of heart disease since 4 years ago, has no

control in the last 1 month.

Swelling of both foot since a week ago, increase

when having activity History of hypertension (+),routinely consume

ramipril since 4 years ago


57/94



Consc : CMC

BP : 110/60 mmHgHR : 130x/

RR : 22x/

T : 37 C

Eye : conjunctiva anemic (-), icterics of sclera (-)Neck : JVP 5+5 mmHg


58/94


59/94

abdomen :




Extremities :

Oedem (-/-)


60/94


61/94


pH : 7,48

pCO2 : 29 pO2 : 141.000/mm3

HCO3- : 215

Beecf : -1,9

SO2 : 99%


62/94

WD :

CHF Fc III LVH RVH AF rapid respon rhythm cb

CAD

Congestive hepatopathy

AKI rifle I cb pre renal cb cardiac output cb AF


63/94


64/94

P :

rontgen thorak

Echocardiography


65/94

MASRIZAL, 75 YO, MALE , MW 11

Cc : diarrhea since 5 days ago

Present illness history ;

Diarrhea since 5 days ago, 10 times a day, about

glass consist of fluid, no blood, no mucous

Fever (-) since 5 days ago, continously, no chill, no

sweat

Cough (+) since 5 days ago, mucous (+), blood (-) Breathlessness since 5 days ago, do not due to

activity


66/94



Consc : CMC

BP : 130/60 mmHg

HR : 96x/

RR : 22x/

T : 37,8 C



67/94

Lung : Inspection : barrel chest, ICS is wider

Palpation : fremitus decreased sinistra et dextra

Percussion : hypersonor

Auscultation: bronchovesicular, rales (+/+)

Heart :

inspection :ictus cordis invisible

Palpation :ictus cordis palpable1 finger medial LMCS

Percussion:heart border : left ;at 1 medial LMCS

Rigth: LSD

Auscultation : irreguler rhythm


68/94

abdomen :



Percussion : tympani

Auscultation : bowel sound (+) N

Extremities :

Oedem (-/-)


69/94

Laboratorium

Hb : 13,6 gr/dl

Leu :26900/mm3

Ht : 40%


Na : 138 mmol/L

K : 3,9mmol/L

GDS : 124 mg/dl

Ureum : 59 mg/dl



70/94

WD :

acute gastroenteritis koleriform type with mild

dehydration

Stable COPD

bronchopneumonia


71/94

Th ;

Rest/ O2 2 L/ i/ low fiber diet

IVFD NaCl 0,9%-- > loading 1 kolf then 8 hours/kolf

Lasidofil 2x1 tab

Salbutamol3x2 mg

Ceftriaxon 1x2 gr

Azitromicin 1x500 mg

Oralit sachet 3x1sch Pct 3x500 mg

Fluid balance


72/94

P :

Feses culture

Expertise rontgen thorak


73/94

HERMAN, 70 YO, MALE, MW 08

Cc ; increasing of Chest pain since a day ago


Increasing of Chest pain since a day ago, reffered

to the back and arm, firstly complain since 5 days

ago, twice a day,the duration about 2 minutes but

lately it becomes 20 minutes

Nausea (-), vomit (-)

Breathlessness (+) do not due to activity

Mixturation was no complain


74/94



Consc : CMC

BP : 120/70 mmHg

HR : 84x/

RR : 28x/

T : 36,4 C



75/94

Lung : Inspection : simetric


Percussion : sonor


Heart :

inspection :ictus cordis was invisible

Palpation :ictus cordis palpable 1 finger medial LMCS

Percussion:heart border : left ;1 finger medial LMCS

Right: LSD



76/94


77/94

Laboratorium

Hb : 5,9 gr/dl

Leu :10000/mm3

Ht : 18%Trombosit : 369.000/mm3

Na : 132 mmol/L

K : 3,9mmol/L

GDS : 160 mg/dl

Ureum : 98 mg/dl

Creatinin : 2 mg/dl


78/94

WD : nonstemi antero lateral

Th ;

Rest /heart diet II/ O2 3 L/I

IVFD NaCl 0,9 % 12 hrs/ kolf

Loading clopidogrel 300mg continue with 1x75 mg

Loading ascardia 160 mg continue with 1x80 mg

Heparin drips bolus 4000u continue with drip 1 cc of heparin in 50 cc Nacl 0,9 % start in 7,2cc/hr( in syringe pump)

cek aptt each 6 hours : APTT ,

95 stop

ISDN 3x5 mg

Bisoprolol 1x2,5 mg

Inj prosogan 2x1 amp

Sucralfat syr : 3x1 C

Fluid balance


79/94

YUSNIAR,FEMALE, 54 YO , FW !@

Cc : palpitation on chest since 1 day ago


palpitation on chest since 1 day ago, like

burn,referred to right hand

Nausea (+), vomit (-) since 1 day ago

Decrease of appetite to eat

Dizziness (+) since 1 day ago


80/94


Consc : CMC

BP : 130/90 mmHg

HR : 72x/

RR : 24x/

T : 37,2 CEye : anemic (-), icterus (-)

Lung : vesiculer, rales (-/-)


Abdomen: Liverand spleen werent palpable, peristaltik was

normalExt : fisiology reflec +/+ (Normal)

pathology reflec -/- (Normal)

Edema (-/-)


81/94


82/94


83/94

P :

Check profile lipid

Echocardigrafi

Gastroscopy

EKG evaluation


84/94


85/94

Physical examination :Consc : CMC

BP : 140/70 mmHg

HR : 102x/

RR : 22x/

T : 36,7 CEye : anemic (+) icterus (-)

Lung : vesiculer, rales (-/-)


Abdomen: Liverand spleen werent palpable, peristaltik normal

Ext : fisiology reflec +/+ (Normal)pathology reflec -/- (Normal)

edema (-/-)


86/94

Laboratorium

Hb : 9,1 gr/dl

Leu : 18400/mm3

Ht : 28%


Na : 125 mmol/L

K : 3,8mmol/LUreum : 336 mg/dl



87/94


pH : 7,33

pCO2 : 21

pO2 : 101

HCO3- : 11,1

Beecf : -14,8

SO2 : 97%


88/94

WD :

Stage V CKD cb PNC with metabolic acidose postNefrostomi bilateral

Th ;

rest/ low salt diet II/ low protein 36 gr

IVFD Eastprimer : D10% =1:1 >12 hrs/kolf

ceftriaxon 1x 2g

Domperidon 3x10mg

Bicarbonat Natrium 3x500mg

Folic acid 1x 5 mg

Candesartan 1x 8 mg

Meylon correction 150 meq in 150 cc NaCl 0,9% fastdrip

Fluid balance


89/94

Plan/

Preperation to Hemodialysis


90/94


91/94

MUSLIH, 52 YO, MALE,MW 25


92/94


93/94

WD :

Decrease of consciousness cb KAD

Sepsis cb abses a/r poplitea dextra

Mild anemia

Aki rifle R cb pre renal cb dehydration


94/94

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Duty Report, June 12th Complete

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