DUTY REPORT


Sept 26th ,2016

dr. Benny
 Lailatul Qadri, Female, 43yo, FW11

 Cc:

 Increased of breathlessness since 1 day ago

 Present Illness History

 Increased of breathlessness since 1 day ago. Affected by activity, not
affected by food and weather. History of wokeup in the midnight
because of breathlessness (+). History of elevated by pillows when
sleeping (+). History of wheezing (-)
 Cough since 1 week ago, sputum (+) yellowish color. Bloody cough
(-)
 Fever since 2 days ago. Not too high. No chill and no exessive
sweating.
 Decreased of appatite (-)
 Decreased of bodyweight (-)
 Patient referred from yarsi Hospital for echocardiography
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 : 130/80 mmHg

 HR : 80x/minute

 RR : 24 x/minute

 T: 36,4 C
 Eye
 Conjunctiva are anemic -/-
 Sclera are icteric -/-

 Neck 
 JVP 5+2 cmH2O

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: left = right fremitus.
 Percussion: sonor
 Auscultation: vesicular, rales -/-, wheezing -/-

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

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


Hb 12,4 gr/dl
Ht 37%
WBC 13.100/mm3
Platelet 379.000/mm3
Ur/Cr 25/0,8
RBG 110 mg/dl
CKMB 11 U/l
 Working Diagnosis


 ADHF wet and warm NYHA III
 Bronchopneumonia (HAP)
 Therapy

 Rest/Heart diet II / O2 3L/1’
 Inj. Cefoperazone 2 x 1gr (iv)
 Inj. Furosemid 2 x 20mg (iv)
 Spironolacton tab 2 x 20mg (po)
 Paracetamol tab 3 x 500mg (po)
 N- acetylsistein tab 3 x 200mg (po)
 Fluid balance
 Planning

 Echocardiography