Duty Report

16 March 2022 MORNING & DUTY REPORT

1 Syafrizal/Male/60 YO/MW 23
Chief Complaint
• Shortness of breath increased since 3 days before admission
Present Illness History
• Shortness of breath increased since 3 days before admission
• Fever not high and cought 3 days before admission
• Swollen in left neck and top of the head since 2 month, began with diameter
approximately like marbles and growth until now as large as tennis ball
• Night sweating since 1 month ago
• Decrease of appattied and loss of weight about 4 kilograms in 2 month
• Intermittent chest pain since 4 days ago, no referred pain, and no nausea and vomitting
• Patient was getting medical care in RSUD Lubuk Basung for 3 days and transferred to M
Djamil Hospital
• History of intravenous antibiotic : ceftazidime 2x1 gr and levofloxacin 1 x 750 mg
• Patient post medical care in yellow zone geriarti for almost 2 days because of covid
suspiction
• No history of previous cancer, tuberculosis, diabetes, and hypertension.
Past Illness History
• History of previous cancer (-)
• History of tuberculosis infection (-)

Family History
• Cancer (-)
Physical Examination VII

• General Appearance : Moderate

• Consciousness level : Composmentis Cooperative

• BP : 120/70 mmHg
• HR : 100 x/minute
• RR : 23 x/minute
• T : 37,5 0C
• SpO2 : 98% with NRM 10 lpm
• Eye and head VII
– Conjunctiva anemic (-/-)
– Icteric sclera (-/-)
– Top of the head : tumour, size 8 x 6 x 4 cm, hard consistency, regular surface,
immobile, no pain
• Neck
– JVP 5-2 cmH20
– Local status : left next : tumour, size 10 x 8 x 5 cm, hard consistency, irregular
surface, immobile, no pain.
• Lung:
– Inspection : statically & dynamically symmetric, retraction (-)
– Palpation : fremitus right = left
– Percussion : sonor in both hemithorax
– Auscultation : bronchovesicular, rales in parakardial bilateral, wheezing (-/-)
• Cor: VII
– Inspection : ictus is not seen.
– Palpation : ictus is palpated at LMCS ICS V
– Percussion :
• Left border : LMCS ICS V
• Right border : linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection : Distension (-)
– Palpation : soepel, hepar and lien are not palpable
– Auscultation : bowel sound (+)

• Extremities:
– Warm
– Oedema (-/-)
– Physiologic Reflex +/+
– Pathologic Reflex -/-

PADUA score : 4 (reduced mobility and acute infection)

Laboratory
Items Value (7/3/2022)
Hb 11,8 gr/dl VII
Ht 35 %
Leukosit 25.640 /mm3
Platelet 408.000 /mm3
MCV/MCH/MCHC 84/28/33
DC 0/0/85/10/5
Alb/Glo 2,9/3,1
SGOT/SGPT 75/34
Na/K/Cl 131/3,8/95
PT/APTT/INR 11/20,5/1,02
D Dimer 1106
Ur/Cr 24/0,6
AGD 7,39/41,3/123/25,2/1,
2/98
Chest X-Ray VII
ECG VII
Problems

dyspnoe
Tumour
leukocytosis
Chest pain
High risk VTE
Abnormal liver function
Working Diagnosis

Hospital acquired pneumonia with risk of MDR

Susp lymphoma maligna
High risk VTE
Ischemia inferio lateral with RBBB
Abnormal liver function
Therapy
• Rest/ soft diet high callories high protein with extra egg
• IVFD NaCl 0,9% 8 hours/kolf
• O2 NRM 10 lpm
• Inj Cefepime 3 x 2 gr
• Inf levofloxacin 1 x 750 mg
• N Acetylsistein 3 x 200 mg
• UDCA 3 x 250 mg
Plan
Sputum culture
Tumour biopsy
Lab test for cardiac marker Troponin I