Duty Report


July 25th, 2017

dr. Rudi Erwin

 Dame Tambunan, Female, 75yo, FW21

 Cc:

 Shortness of breath increased since 1 day ago

 Present Illness History

 Shortness of breath increased since 1 day ago. Shortness of breath affected by
activities and not affected by food and weather. PND (-), DOE (-), OP(-).
History of elevated by pillows when sleep for decreased of breathlessness.
History of woke up at the midnight because of shortness of breath (-).
Wheezing (-).
 Cough since 1 week ago. Sputum (+), yellowish color. Bloody cough (-)
 Fever since 5 days ago. Intermittent.not too high. No chill and exessive
sweating.
 Decreased of appatite (+)
 Decreased of bodyweight (+)
 No nausea and vomite
 Micturation and defecation 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 : 86x/minute

 RR : 24x/minute

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

Neck
JVP 5-2 cmH20

Lung:
Inspection: simetric at statis and dinamic
Palpation: Left = Right Fremitus
Percussion: sonor
Auscultation: Bronchovesiculer, Ronchi (+/+), wheezing (-)

Cor:
Inspection: ictus not seen
Palpation: ictus is palpated at 1 finger medial LMCS ICS V
Percussion:
Left border: 1 finger medial LMCS ICS V
Right border: linea sternalis dextra
Upper border: RIC II
Abdomen:

 Inspection: enlargement (-)
 Palpation: Liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

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

Hb
Ht
10,0 gr/dl
28%
 PH
PCO2
7,37
24
WBC 6.680/mm3 PO2 39
Platelet 325.000/mm3 HCO3- 13,9
RBG 95 mg/dl BE ecf -11,4
Na/K/Ca 126/2,7 SO2 72%
Ur/Cr 25/0,6
Rontgen Thorax

ECG

 Working Diagnosis
 Primary Diagnosis :

Decreased od conciousness cb Hypoxemia

 Secondary Diagnosis :
 Bronchopneumonia (CAP)
 Hyponatremia et Hypokalemia cb low intake
 Therapy


 Rest/Liquid Diet 6x200cc via NGT/NRM 10 L/1’
 IVFD NaCl 0,9% * hours/colf
 Inj. Cefoperazone 2x1 gr (IV)
 Correction of NaCl 3%12 hours/colf (1 colf)
 Correction of KCL 35 mEq in 200cc NaCl 0,
 Plan

 Sputum culture