Duty Report

2 Februari 2022 MORNING & DUTY REPORT

1 Andi Imam Putra/Male/38YO/MW 21
Chief Complaint
Diarrhea since 1 week ago

Present Illness History

• Diarrhea since 1 week ago, frequency was 5-6 times a day, no black defecation
• Fatigue and weakness since 1 week ago
• Decrease of weight more than 10 kg in 3 months
• Loss of appetite since 1 month ag0
• Fever since 7 days ago, not high, not continue
• There is no nausea and vomite
• There is no breathlessness
• There in no bleeding gums and nosebleed
• Micturition and Defecation was normal
• Patient has been known as AML M5 (BMP had been done on 13 January 2022, the result was
AML-M5)
Past Illness History
• History of DM since 10 years ago, medication : apidra 3x8 unit,
Levemir 1x14 unit
• No history of hypertension

Family Illness History

• No family members suffer from the same complaint
Physical Examination VII

• General Appearance : Moderate

• Consciousness level : Compos Mentis Cooperative

• BP : 120/80 mmHg

• HR : 80 x/minute

• RR : 20 x/minute

• T : 38,9 C

• SpO2 : 99%
• Eye VII
– Conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung: normochest
– Inspection: symmetric right = left
– Palpation: fremitus right = left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is 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: ICS II
– Auscultation: regular, murmur (-), gallops (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen are not palpated
– Percussion: tympani
– Auscultation: bowel sound (+)

• Extremities:
– Oedema -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
– ABI : 0,9/0,9

• Pulsation artery
- A brachialis +/+
- A . Radialis +/+
- A. dorasalis pedis +/+
- A. tibialis posterior +/+
Pedigree Status VII
Diabetic Status VII

• Weight : 60 kg, height : 160 cm

• Ideal body weight : 54 kg
• BMI : 24,43
• Calori needed : 54 x 30 =1620 kkal
• Age > 40 th : -5%
• Mild activity : +10%
• Metabolic stress : +10%
• Total diet = 1863 kkal
 Laboratory
Items Value VII
Hb 6,7 gr/dl
Ht 26 %
Leukosit 32.970 /mm3
Platelet 145.000/mm3
Diff. Count (B/E/NB/NS/L/M) 0/1/2/11/17/2 blast cells 65%, mielosit
2%
Albumin/ Globulin/ Total protein 3.5/5.2/8.7

PT/APTT 11.2/25.8

Ur/Cr 47/1.8
Na/K/Cl 132/4.1/105
RBG 310
Chest X-Ray VII
ECG VII
Peripheral Blood Smear
Problems

• Leukemia
• Anemia
• Trombositopenia
• AKI Stage 1
• DM type 2
Working Diagnosis

• Acute myeloblastic leukemia M5 pro chemotherapy

• Bisitopenia cb leukemic cells infiltration
• Type 2 DM not controlled normoweight
• AKI Stage 1
Therapy
• Rest/ diet high protein high calori, diabetic diet 1800 ccal
• IVFD Nacl 0,9% 8 hours/kolf
• Paracetamol 3x500 mg
• Folic acid 1x5 mg
• Novorapid 3x 10 units
• Levemir 1x16 units
• Vitamin B complex 2x1
Plan
• Chemotherapy
• Blood transfussion