Duty Report

Emergency Ward
27th January 2016
General Practitioner on
Duty:
Dr. Gerald
Dr. Dina

Co-Ass on Duty:
Colin
Bayu

Patient Recapitulation
Ms. S, 61 years old. Hepatitis
Mr. DA, 25 years old. Dyspepsia,
Pickwickian syndrome
Mr. D, 45 years old. Febrile
observasion
Ms. G, 62 years old. Dypsneu e.c CHF
Grade 3
Ms. J, 59 years old. C.a cervicks

Patient Identity

Name : Mr. DA
Medical Record Number : 010839
Date of birth : 9th August 1990
Religion : Moslem
Marital Status : Unmarried
Occupation : Jobless
Address : Senen, Jakarta Utara
Date of entry: 27th January 2016

Anamnesis
Auto & Allo anamnese on 27th
January 2016
Current Medical Record:
- Patient came to emergency ward complaining
about his abdominal cramp on whole of
abdomen, felt since 5 days before admission,
aggravated by cough. Patient also complaints
about having both of his legs swollen since 2
weeks before admission. He also complaints of
difficulty in urinating for 6 days, defecating for 3
days, and being out of breath, especially at
noon, feeling better if he sits or given oxygen
and worsen if he sprawl. The patient admits that
he needs constant supply of oxygen to relief his
shortness of breath, even at home. He also

Past Medical History:

Heart enlargement

Family Medical History:

Heart diseases (-)
Pulmonary diseases (-)
Hypertension (-)
Diabetes (-)
Renal diseases (-)

Drug Records:
Valsartan 80mg
Ivabradin 5mg

Physical Examination
Awareness: Compos Mentis
BP : 134/77mmHg
HR : 107 x/min
RR : 31 x/min
Temp : 36.8oC
Weight : 135 kg
Height: 160 cm
IMT : 52.7

Status Generalis
Head : normocephal
Eye : anemic conjunctivae -/-, icteric sclera
-/Ear : normotia, secretions (-)
Nose : septum nasi deviation (-), secretions
(-)
Throat : tonsil T1-T1, calm
Mouth : moist oral mucous, cyanosis (-)
Neck : JVP 5+0

Thorax
Pulmo

:
Inspection : symmetric hemithorax left and right
Palpation : tactile fremitus left = right (?)
Percussion : sonor
Auscultation : Vesicular +/+, rhonkhi -/-, wheezing -/-

Cor

:
Inspection : ictus cordis ()
Palpation : palpable ictus cordis
Percussion : In normal range
Auscultation : S1-S2 normal, regular, murmur (-), gallop (-)

Abdomen
Abdomen
Inspection : Raised, distension (+)
Auscultation : BU (+) normal
Palpation : tenderness (+) on hypogastric
region, hepar and lien not
palpable
Percussion : timpanic (?) on whole region of
abdomen, CVA -/Extremity : Warm, CRT < 2 sec, Foot Edema
+/+

Problem List
Dyspepsia ec. urine retention
Pickwickian Syndrome

Assesment
Dyspepsia ec. Urine retention
Anamnesa:
Abdominal cramping since 5 days before admission
Oligouria since 6 days before admission
Physical examination:
Abdominal tenderness (+) on hypogastric region
Patient felt relieved after installation of urinary catheter
Treatment:
- Urinary catheter

Pickwickian syndrome
Anamnesa:
Constant shortness of breath, especially at
noon
Frequently awake at early morning, feeling out
of breath
Physical Examination
IMT of 52.7 (> 30)
Foot edema +/+
Treatment:
Furosemide
Education on diet and lifestyle

Prognosis:
Quo ad Vitam
: Dubia ad bonam
Quo ad Functionam : Dubia ad malam
Quo ad Sanationam : Dubia ad malam

Obesity
Hypoventilation
Syndrome)

Syndrome

(Pickwickian

OHS is a breathing disorder in obese people that leads

to low oxygen levels and too much carbon dioxide in
your blood. Low oxygen and high carbon dioxide levels
may develop because of a condition called
hypoventilation
during
the
day
(daytime
hypoventilation). Hypoventilation means you are not
moving enough air in and out of your lungs very well.
With OHS, you may also have difficulty sleeping
because of obstructive sleep apnea.
The three main characteristics of OHS are:
1) obesity
2) daytime hypoventilation (difficulty getting rid
of carbon dioxide)

Thank You