Duty Report

21 MEI 2021
 Asenopita, female, 24 yo, HCU 03
Chief Complaint :
• Breathlessness increased since 4 days ago

Present Illness History :

• Breathlessness increased since 4 days ago, has been felt since 1
month ago. Breathlessness affected by activity, not affected by
weather or food.
• Chest pain (-)
• Fever since 4 day ago, fever not really high, no excessive sweating.
• Cough since 4 day ago, sputum (+) blood (-)
• Nause (+) and vomit (-)
• History of swelling both of leg (+)
• post partum 5 days ago
• Defecation and micturition was normal
• Patient was transferred from Yellow zone
 Pass Illness History :
• History of HT (-)
• History of DM (-)

Social and Family History

• There is no family who had same illness
Physical Examination
• General appearance : moderate
• Consciousness level : CMC
• BP : 100/70 mmHg
• HR : 98 x/minute
• RR : 20 x/minute
• T : 37
• Sat : 99%
• Skin
Turgor normal
• Lymph nodes
No enlargement on the neck, armpit and thigh area
• Head
Normocephal
• Eye
◦ Conjunctiva anemic (-)
◦ Sclera icteric (-)
• Neck
◦ JVP 5-2 cm H2O
• Lung :
◦ Inspection : normochest, symmetric static and dynamic
◦ Palpation : fremitus increased at both of lung
◦ Percussion : sonor
◦ Auscultation : bronchovesicular, ronchi +/+ in bilateral
pulmonary field, wheezing -/-

• Cor :
• Inspection : ictus not seen
• Palpation : ictus is palpated at 2 finger medial LMCS ICS VI
• Percussion :
 Left border : 2 finger medial LMCS ICS VI
 Right border : linea sternalis dextra
 Upper border : RIC II
• Auscultation : Heart sound regular, murmur (-)
• Abdomen :
• Inspection : enlargement (-)
• Palpation : unpalpaple
• lien not palpable
• Percussion : tympani
• Auscultation : bowel sound (+) normal

• Extremities :
• Oedema -/-
Laboratory
Hb 13.9 g/dL

Ht 44 %

WBC 25.010 /mm3

Platelets 194.000/mm3

Diff count 0/0/88/7/5/

Ur/Cr 30/1.4 mg/dL

SGOT/ SGPT 30/11 U/L

Alb/ Glb 2.3/3.1 g/dL

PT/APTT/INR/DDimer 10.2/28.7/0.92/ >10.000

Na/K/Cl 135/3.6/107

ph/ pco2/po2/hco3/be/so2 (4/4) 7,436/ 32.1/ 140.4/ 21.9/-2.6/ 98.9%

Troponin I 64
ECG

• Irama sinus, HR : 99x/m gel P : 0.08, QRS :<0.12, segment ST elevasi

(-), depresi (-), gel T inverted (+) V3-V4, axis : normal
• Kesan : sinus rythm HR 99 dengan RBBB
Chest X-Ray
Working Diagnose
• CHF FC II ec PPCM
• Hospital acquired pneumonia
Therapy
• Rest/ cor diet 1500 call
• O2 3 lpm
• IVFD NaCl 0,9% 12 hours/kolf
• Furosemid 2 x 20 mg
• Inj Cefepime 3x2 gr iv
• Inf Levofloxacine 1x 750 mg iv
• N-acetylsistein 3x200 mg po
• Paracetamol 3x500 po (K/P)
• Atorvastatin 1 x 20 mg
• Bisoprolol 1 x 2,5 mg
Plan
• Echocardiografi
• Culture sputume