Duty report

january 3th, 2018

Nadia 18 yo, FW 20
 Breathlessness increase since 1 day ago. Actually felt
since 1 weeks ago. Not influenced by actifity, food and
weather. Sleep with elevated pillow (-)
 Fever since 3 weeks ago, not high and not chill
 Cough since 3 week ago. Sputum (+)
 Nausea and vomit (-)
 fatique since 1 weeks ago.
 Decrease of body weight since 2 weeks ago.
 Decrease of apettite since 1 months ago
 Mixturation and defecation was normal
 Patient had been reffered from RS ibnu sina with lung
TB and anemia
04/01/2018
Physical Examination
 level of consciousness : CMC

 BP : 110 / 70 mmHg

 HR : 130 x/minute

 RR : 26 x/minute

 T: 37,9oC
 Eye
◦ Conjunctiva are anemic +/+
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation: bronchovesicular, Rh+/+, Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medial LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur(-)
 Abdomen:
◦Inspection: Enlargement (-)
◦Palpation: hepar and spleen unpalpable
◦Percussion: tympani
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema -/-
Laboratory
Examination Result
Hb 8,6 g/dl
Leukosit 13850/ mm3
Trombosit 42800/ mm3
ht 26
Ur / Cr 32/0.9
GDS 138
NA/K 136/3,7/102
Na / K / 14/0,7 /
Ph 7,44
Pco2 36
Po2 42
Hco3- 24,5
Beecf 70.3
so2 80

04/01/2018
Working Diagnose
 Bronchopneumonia dupleks (CAP) with
respiratory failure type 1
 TB milier
 Mild anemia normocytic normochorm cb
chronic disease
Therapy
 rest / soft diet high calory high protein / NRM 02 10 l/i
 IVFD nacl 0,9 % 8 hr
 Ceftriaxone 1x2 gr
 Paracetamol 3x 200 mg
 Nebu flumucyl/ 8 hr
 Fluid balance