Duty Report

Thursday, April 30th 2015

Physician In Charge:
IA : dr. Camelia, dr. Rakhmi, dr. Intan, dr. Jaja
IB : dr. Vina, dr. Awan
II ER : dr. Rizal, dr.Arya
Chief : dr. Eva Carolina
III : dr. Sri Sunarti, Sp.PD-KGer
Summary Of Database:
Mrs.Siti Juwita/ 56 Y.O/W 25
Chief Complaint: General weakness
Patient presented with the chief complaint general weakness since 2 weeks ago. Weakness was
persistent and getting more severe with activity in 1 weeks. She almost told that there is a lump in her anal
since 2 weeks ago. The anal cushions prolapse through the anus and require manual replacement into the anal
canal. When she passing stool there some fresh blood covering the stool.
She had been Diagnosed with AIHA in 2010, at the time she came to RSSA ER with the chief complain
Fatique. After hospitalitation and got several examination , the doctor told that she suffered from AIHA.
Then the doctor gave her metylprednisolon 3x16 mg and tapering off until now she consumed metylprednisolon
1x4mg.
She also complained about abdominal discomfort since about 2 weeks ago. She told that she felt
abdominal pain especially in the epigastric area when she skip meal or after eating spicy food, the pain is like
burning sensation and the pain subsided after he consumed antacida. He also complained about decreased of
apetitte and she just eat 4-5 spoons/meal.
She Had history of Hypertension since 1 years ago and routinely consumed valsartan 1 x 80mg.

History of past illness: There is no history of DM.

Family History: No history of blood disorder in family.
Social History: She is a housewife , work as teacher. She had 4 Children She is a housewife.
Physical Examination
BP= 140/80 mmHg PR= 100 bpm regular RR =20 tpm Ax. Temp.= 36 0C
strong
General App: looked moderately ill GCS : 456
Looked normoweight
Head Anemic conjunctiva (+) Icteric sclerae (-) PEERL 3 mm/3 mm
Neck JVP : R + 1 cm H2O; 300, Lnn enlargement (-)
Thorax Cor Ictus invisible, palpable at 2 cm lat ICS V, MCL S
RHM ≈ SL D
LHM ≈ ictus
S1, S2 single, murmur -, gallop -
Pulmo Symmetric; SF D=S; S| S V |V Rh -| - Wh - | -
S| S V |V -| - -|-
S| S V |V -| - -|-

Abdomen BS (N), Liver span 8 cm, traube’s space tympany, shifting dullness (-) , epigastric
pain (-), Soefl
Extremities Edema (-), warm

LABORATORY FINDINGS
LAB RESULT NORMAL VALUE
Leukocyte 5290 3,500-10,000/µL
Hemoglobine 3,80 11.0-16.5 g/dl

Hematocrite 14% 38-42%

Thrombocyte 397000 150,000-500,000/µl
SGOT 11 11-41U/L
SGPT 6 10-41U/L
Diff count 0/1,0/0,0/76/17/6,0 0-4/0-1/51-67/25-33/2-5
Eos/Ba/Neu/Ly/Mo
Coombs Test +2 Neg
LDH 268 240-480 U/L
Bil T/D/I 0,11/0.06/0,05 <0,1/<0,25/ <0,75
MCV 72,50 80-93
MCH 19,70 27-31

UA 6 2.6
Ur 17.8 10-50 mg/dL
Cr 0.53 0.7-1.5 mg/dL
 Blood smear:
Erytrocyte: Hypochrome Microcytair anisopoikilositosis, cigar cell +, Fragmentosit +
Leucocyte: normal
Thrombocyte: normal

ECG:
• Sinus rhythm, Heart rate 94 bpm
• Frontal Axis : normal
• Horizontal Axis : normal
• PR interval : 0.20”
• QRS complex : 0.06”
• QT interval : 0.36”
• Conclusion : sinus tachycardia with HR 94bpm

CUE&CLUE PL IDx PDx PTx PMo

1.Female / 56 YO 1.AIHA Bedrest Subj
AX : IVFD NS 0.9% 20 dpm VS
General weakness HCHP diet 2100 kcal/day CBC
Dizziness 02 2-4 lpm NC
PE Inj Metylprednisolone 2x 125
Anemic (+) mg intravena
Lab: B6/B12 3x1 tab
Hb 3,8 g/dl Folic acid 2x3 tab
LDH 268
Coombs’ Test +2
MCV 72,5
MCH 19,70
Blood smear:
Hypochrome
Microcytair
anisopoikilositos
is, cigar cell +,
Fragmentosit +
2.Female / 56 YO 2. Anemia 2.1 Occult Blood PRC Transfusion 2 pack/Day Subj
AX : Hipochrome Loss until Hb > 10 g/dl VS
History of Mycroistair
Hemmorhoid
PE :
Anemi (+)
Hb 3,8 g/dl
MCV 72,5
MCH 19,70
 CUE&CLUE PL IDx PDx PTx PMo
3.Female / 56 YO 3.Dyspepsia 3.1 Gastritis Omeprazole 2x20mg Subj
AX : Syndrome erosive VS
Abdominal 3.2 PUD CBC
discomfort
Epigastric Pain
Lab:
4.Female / 56 YO 4. Haemmoroid Anti Hemmoroid Subj
AX : grade III supposituria 1x1 VS
History of Tranexamic Acid 3 x 500mg if Bleeding
Hemmorhoid still bleeding
Plan to consult to Digestive

5.Female / 56 YO 5. Hypertension on Valsartan 1 x 80mg Subj

Ax : Treatment Vs (Blood
Pressure)