DUTY REPORT


August 20th ,2018

dr. Rudi Erwin

 Abdul Arif, Male, 67yo, HCU15

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

 Present Illness History

 Shortness of breath increased since 1 day ago. Shortness of breath affected
not affected by activity, food and weather. PND (-), OP (-), DOE (-).
 Cough since 1 week ago. Sputum (+), yellowish color. Bloody cough (-).
 Fever since 5 days ago. Not too high. No chill and no exessive sweating.
 Nausea and vomite denied
 History of black stool (+) since 10 days ago. Freq 2-3x/days.
 Patient has been known gout arthritis and got therapy analgetic from
drug store since 5 years ago.
 Patients referred from Parit Malintang Hospital and had been
hospitalized since 12 days ago and got transfusion of PRC for 2 unit.
 Micturation and defecation normal
 
Past Illness History
• History of HT denied
• History of DM (-)
• History of Gout arthritis

Family Illness History

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

 BP : 155/100 mmHg

 HR : 92x/minute

 RR : 26x/minute

 T: 36,7 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: 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: Soepel, liver and spleen no palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Oedem +/+
 Physiologic reflex +/+
 Patologic reflex -/-
 Laboratory

Hb 10,5 gr/dl  PH
Ht 32% PCO2
WBC 9.030/mm3 PO2
Platelet 518.000/mm3 HCO3-
PT/aPTT 13,2/58,2 BEecf
Ur/Cr 23/1,2 mg/dl SO2
Na/K/Cl/Ca 129/3,5/98 Mmol/L
RBG 118 mg/dl


 Working Diagnosis

 Hospitalized Acquired Pneumonia
 Gastropathy NSAID post melena
 Gout Arthritis
 Hypertension stage I cb Essensial
 Hyponatremia cb low intake

Dd/
 Lung TB
 Peptic ulcer post melena
 Therapy

 Rest/Soft diet low purin Gastric diet II Low salt II/ O2 3L/1’
 IVFD NacL 0,9% 8 hours/colf
 Inj. Ceftazidime 3x1 gr (iv)
 Inf. Levofloxacine 1x500 mg (iv)
 Inj. Flumucyl 3x300 mg (iv)
 Paracetamol tab 3x500 mg (po)
 Candesartan tab 1x8 mg (po)
 Lansoprazole cap 1x30 mg (po)
 Sucralfat syr 3x10cc (po)
 Fluid balance
 Planning

 Culture sputum
 Esophagogastroduodenoscopy