Duty report

August 23th, 2017

Filmatri Yuliar, Male, 49 yo,

Chief complain
Breathlessness increased since 2 days ago
 Present illness history
breathlessness has increased since 2 days ago.
Actually has been felt since 1 week ago.
breathlessness is not affected by activity, weather,
and food. Sleep with elevated pilow (-).
Cough since 1 month ago, with sputum. Coughing
blood (-).
Fever since 2 days ago. Not high and not chill. Not
sweating a lot.
Decreased appetite since 1 week ago
Weight loss since 2 days ago
Patient had been hospitalized 2 weeks ago with
effusion pleura and had been tapping pleura effusion.

25/09/2017
Physical Examination
level of consciousness : CMC

BP : 100 / 70 mmHg

HR : 100minute

RR : 30 x/minute

T: 27 oC
 Eye
Conjunctiva are anemic +/+
Sclera icteric -/-

Neck
JVP 5 - 2cmH20

Lung:
Inspection: asimetric
Palpation: fremitus decrease at lung dextra
Percussion: dullness as high as RIC III down below lung dextra
Auscultation : Bronchovesicular, Rh +/+, Wh -/-, sound of breath
decrease as high as RIC III down below lung dextra

Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger medial LMCS RIC V
Percussion:
Left border: 1 finger medial LMCS RIC V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: Pure rhythm, murmur(-)
 Abdomen:
Inspection: Enlargement (-)
Palpation: liver and spleen not palpable
Percussion: tympani
Auscultation: bowel sound (+) normal

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory
Examination Result
Hb 8,6 g/dl
Leukosit 11.660 / mm3
Trombosit 727.000 / mm3
Hematokrit 26 %
GDS 112
Ur / Cr 21/0,7
Ph 7,465
Pco2 31
Po2 27,5
Hco3- 22.6
Beecf -1,4
so2 56,9

25/09/2017
Working Diagnose
Pleural effusion dextra ec malignancy
Mild aneimia normocytic normochromic
ec chronic disease
Trombocytosis reactive
Bronchopneumia duplex (HCAP) with
respiratory failure type 1
Therapy
rest / soft diet / O2 4L / I
IVFD NaCl 0.9% 12 hours / kolf
Ceftazidine 2 x I mg
Levofloxacin 1 x 500 mg
Paracetamol 3x 500 mg
Nebu flumucyl /8 hours
fluid balance