DUTY REPORT


August 07th ,2018

dr. Rudi Erwin

 Muchtar narit, Male, 81yo, MW21

 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
activity and not affected by food and weather. PND (+), OP (+), DOE (+).
 Cough since 3 months ago. Sputum (+), yellowish color. Bloody cough (-).
 Swelling on the leg since 2 weeks ago.
 Fever since 3 days ago. Not too high. No chill and no exessive sweating.
 Decreased of appatite (+)
 Decreased of bodyweight denied
 Nausea and vomite denied
 History of sweat night without of physical activity (+)
 History of black stool (+)
 Patient has been known CHF and liver cirrhosis
 Patient had been transfusion of PRC 3 unit.
 Micturation and defecation normal
 
Past Illness History
• History of HT (+) since 5 years ago. Not regularly controlled
• History of DM (-)
• History of yellow disease denied

Family Illness History

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

 BP : 130/80 mmHg

 HR : 115x/minute

 RR : 28x/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 2 fingers lateral LMCS RIC VI
 Percussion:
 Left border: 2 fingers lateral LMCS ICS VI
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: Soepel, liver no palpable and spleen S2
 Percussion: tympani
 Auscultation: bowel sound (+)

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

Hb 11,9 gr/dl  PH 7,46

Ht 36% PCO2 32
WBC 21.210/mm3 PO2 53
Platelet 67.000/mm3 HCO3- 22,8
PT/aPTT 63,9/>300 BEecf -1,0
D’Dimer 5666,53 ng/ml SO2 89%
Ur/Cr 107/1,4 mg/dl
Na/K/Cl/Ca 135/4,3/103 Mmol/L
RBG 99 mg/dl


 Working Diagnosis

 ADHF wet and warm
 Sepsis cb Hospital acquired pneumonia with
hypoxemia
 Liver cirrhosis post necrotic decompensated stage
child phug B
 AKI stage I cb pre renal cb low cardiac output
 DIC non overt

Dd/
 Lung tuberculosis
 Cardiac cirrhosis
 Therapy

 Rest/Heart diet II low salt II liver diet II/ O2 NRM 10L/1’
 Drip furosemide 100 mg in 50cc NacL 0,9% (syringe
pump) start fast 5mg/hours
 Inj. Meropenem 3x1 gr (iv)
 Inj. N-acetylsistein 3 x 300mg (iv)
 Candesartan tab 1 x 8 mg (po)
 Bisoprolol tab 1 x 2,5 mg (po)
 Spironolactone tab 1x100mg (po)
 Lactulac syr 3x10cc (po)
 Fluid balance
 Planning

 BTA I,II,III
 Abdominal USG