DUTY REPORT


Jan 10th ,2018

dr. Rudi Erwin

 Alamsyah, Male, 64yo, MW16

 Cc:

 Shortness of breath increased since 2 days ago.

 Present Illness History

 Shortness of breath increased since 2 days ago. Shortness of breath not
affected by activity, food and weather. PND (-), OP (-), DOE (-).
 Cough since 6 days ago. Sputum (-). History of bloody cough (-).
 Fever since 6 days ago. Intermittent. No chill and no exessive
sweating.
 Nausea and vomite since 5 days ago. Freq 2x/days. Volume ¼ - ½
glass/x vomite.
 Decreased of appatite (+)
 Decreased of bodyweight denied
 Constipation since 5 days ago.
 Micturation was normal
 
Past Illness History
• History of HT (-)
• History of DM (-)

Family Illness History

• Nothing family with the same of diasease
 Physical Examination

 Consciousness level : CMC

 BP : 120/70 mmHg

 HR : 96x/minute

 RR : 26x/minute

 T: 37,4 C
 Eye
 Conjunctiva are anemic -/-
 Sclera are icteric -/-

 Neck 
 JVP 5-2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: Fremitus right = left
 Percussion: sonor
 Auscultation: Bronchovesicular, rales +/+ , wheezing -/-

 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 1 finger medial LMCS RIC V
Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema -/-
 Laboratory

Hb 13,3 gr/dl
PH 7,48
Ht 39% PCO2 31,6
WBC 18.360/mm3 PO2 60,3
Platelet 190.000/mm3 HCO3- 24,2
Ur/Cr 143/3,6 BEecf 0,6
Na/K/Cl 133/2,6/92 SO2 92,9
RBG 126 mg/dl


 Working Diagnosis
Primary Diagnosis :

 Bronchopneumonia (HCAP) with Hypoxemia

Secondary Diagnosis :
 Dyspepsia syndrome
 Constipation
 Acute on CKD
 Hypokalemia

Differential Diagnosis :
 AKI RIFFLE I cb pre renal cb dehydration
 Lung TB
 Therapy

 Rest /Liquid diet 6x200cc via NGT/O2 3L/1’
 IVFD NacL 0,9% 6 hr/colf
 Inj. Ceftazidime 2x1 gr (iv)
 Azytromicin 1x500 mg (po)
 Paracetamol tab 3x500 mg (po)
 Nebu flumucyl/ 8 hour
 Lansoprazole 1x30 mg (po)
 Lactulac syr 3x10cc (po)
 Sucralfat syr 3x10cc (po)
 Fluid balance
 Planning

 Sputum culture