Duty on November 28th 2018

 Name : HR
 MR : 18048911
 Age : 39 y.o
 Sex : Male
 Religion : Christian
 Status : Single
 Addres : Denpasar
 Date Of Arrival : October 28th 2018 at 23:00 WITA
Chief Complaint : shortness of breath
Present Illness
Patient came to Sanglah hospital, chief complain was shortness of breath
since 14 days BATH (23.00 WITA 28/11/2018). He felt like tightness in his
chest. This shortness of breath kept on getting worse so he can’t do daily
activity since 3 days BATH.
 Patient other complaints are coughs with white sputum since
14 days BATH,
 Weight loss since 1 month ago, but doesn’t calculated.
 Fluctuative Fever since 14 days BATH, get better with drug
 Sprue appeared and gone since 1 month BATH
 Normal defecate and urination
Past history
 Past history of patient was Asthma since 30 years ago, the symptoms
occurs when he stricken by the dust. He didn’t use drug to treat it
Family History
 His all family members have same symptoms of shortness of breath
with the patient.

Social History
 Patient had sex with his friend 3 years ago. Patient was smoker.
Present State
 Appereance : Moderate ill
 Consciousness : Compos Mentis (GCS E4V5M6)
 Blood Pressure : 90/60mmHg
 Pulse Rate : 112x/mnt
 Respiration Rate : 22x/mnt
 Temperatur axilla : 39,4 0 C
 SpO2 : 90% nasal canul
General State
 Eyes : anemic (-/-), Pupil reflex (+/+), oedem palpebra (-/-)
 ENT : Ear : Secret (-/-), normal shape
Nose : Secret (-/-), normal shape, epitaksis (-/-)
Throat : Tonsil T1/T1, Pharyngeal hyperemis (-) Ulcer (+)
 Neck : JVP PR 0 cmH2O, Lymph Node enlragement (-)
 Thorax : Symetric (+), Retraction (-), Deformity (-)
Cor : Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion : Right Border : PSL Dextra
Left Border : MCL Sinistra
Upper border : ICS II Sinistra
Auscultation : S1 S2 normal, Reguler, murmur (-)
General State
 Pulmo
Inspection : Symetric
Palpation : Focal fremitus normal
Percussion : Sonor|Sonor
Auscultation : BVesikular+|+ Ronchi -|- Wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
 Abdomen
Inspection : Distention (-)
Auscultation : Bowel Sound (+) normal
Palpation : Abdominal pain (-) Hepar/Lien Unpalpable
Percussion : Tympanhy (-), Shifting dullness (-)
 Ekstremity : warm , pain, Pruritus Papular Eruption (+)
Parameter Result Unit Reference Range Keterangan

WBC 7.55 10µ/microL 4.1 - 11.0

NE% 84,50 % 47 - 80 HIGH
LY% 8.47 % 13 - 40 LOW
MO% 7.04 % 2.0 - 11.0
EO% 2.44 % 0.0 - 5.0
BA% 0.69 % 0.0 - 2.0
NE# 6.38 10µ/&microL 2.50 - 7.50
LY# 0.64 10µ/&microL 1.00 - 4.00 LOW
MO# 1.06 10µ/&microL 0.10 - 1.20
EO# 0.37 10µ/&microL 0.00 - 0.50
BA# 0.1 10µ/&microL 0.0 - 0.1
RBC 3.83 106/&microL 4.0 - 5.2 LOW
HGB 11,76 g/dL 13.5 - 17.5 LOW
HCT 32.16 % 36.0 - 46.0 LOW
MCV 86.27 fL 80.0 - 100.0
MCH 29.18 pg 26.0 - 34.0
MCHC 36.56 g/dL 31 - 36 HIGH
RDW 12.28 % 11.6 - 14.8
PLT 150.20 10µ/&microL 140 - 440
MPV 6.13 fL 6.80-10.0 LOW
 Ketera
Parameter Result Unit Reference Range
ngan
SGOT
AST/SGOT 60.6 U/L 11.00 - 27.00 HIGH
SGPT
ALT/SGPT 28.00 U/L 11.00 - 34.00
Albumin
Albumin 3.00 g/dL 3.40 - 4.80 LOW
BS Acak / Glukosa Acak
/ Glukosa Sewaktu Glukosa Darah 92 mg/dL 70 - 140
(Sewaktu)
BUN / Ureum
BUN 7.80 mg/dL 8.00 - 23.00 LOW
LDH 1099 U/L 240-480 HIGH
Kreatinin 0.67 mg/dL 0.70-1.20 LOW
Asam Urat 5.0 mg/dL 2.00-7.00
Kalium(K)-Serum 4.45 mmol/L 3.50-5.10
Natrium(Na)-Serum 129 mmol/L 136-145 LOW
 Reference
Parameter Result Unit Keterangan
Range
pH 7.50 7.35 - 7.45 Tinggi
pCO2 34.3 mmHg 35.00 - 45.00 Rendah
pO2 189.50 mmHg 80.00 - Tinggi
100.00
BEecf 2.60 mmol/L -2 - 2 Tinggi
HCO3- 25.90 mmol/L 22.00 - 26.00
SO2c 99.4 % 95 % - 100 %
TCO2 26.90 mmol/L 24.00 - 30.00
Natrium (Na) 132 mmol/L 136 - 145 Rendah
Kalium (K) 3.69 mmol/L 3.50 - 5.10
Klorida (Cl) 80 mmol/L 96 - 108 Rendah
 Cor : besar dan bentuk normal
 Pulmo : tak tampak infiltrat/nodul,
corakan bronchovaskuler
meningkat.
 Sinus pleura kanan kiri tajam.
 Diapragma kanan kiri normal
 Tulang : tak tampak kelainan

 Kesan : Bronkitis
1. Susp. Infeksi HIV Stadium IV (WHO)
-Wasting Syndrome
-Susp PCP
-Oral Candidiasis
-Papular Priuritus Eruption
 Therapy
 NaCl 0,9 % 20 tpm
 O2 10 lpm Nasal Canul
 N-Acetylcysteine 10 drops every 8 hours oral
 Kotrimoxasol 900 g every 8 hours oral
 Paracetamol 500 gram every 8 hours oral
 Prednison 40 mg every 12 hours oral
 Ceftrizine 10 mg every 24 hours oral

 Diagnostic
Monitoring
 Tes anti HIV
•Vital sign
 KOH Swab •Complaint
 PCR