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  • Lap Jaga Jawanis

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    Riko Jumattullah
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    A 73-year-old female presented with fever for 1 day, fatigue for 1 month, cough for 4 days, and pale skin for 1 month. Physical examination revealed decreased breath sounds and rales in both lungs. Laboratory results showed low hemoglobin, hematocrit, leukocyte and platelet counts. The working diagnoses were septic bronchopneumonia and pancytopenia due to anemia aplasia. Treatment included IV antibiotics, steroids, oxygen and blood product transfusions. Further testing with sputum and blood cultures was planned.

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    A 73-year-old female presented with fever for 1 day, fatigue for 1 month, cough for 4 days, and pale skin for 1 month. Physical examination revealed decreased breath sounds and rales in both lungs. Laboratory results showed low hemoglobin, hematocrit, leukocyte and platelet counts. The working diagnoses were septic bronchopneumonia and pancytopenia due to anemia aplasia. Treatment included IV antibiotics, steroids, oxygen and blood product transfusions. Further testing with sputum and blood cultures was planned.

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    3 views7 pages

    Lap Jaga Jawanis

    Uploaded by

    Riko Jumattullah
    A 73-year-old female presented with fever for 1 day, fatigue for 1 month, cough for 4 days, and pale skin for 1 month. Physical examination revealed decreased breath sounds and rales in both lungs. Laboratory results showed low hemoglobin, hematocrit, leukocyte and platelet counts. The working diagnoses were septic bronchopneumonia and pancytopenia due to anemia aplasia. Treatment included IV antibiotics, steroids, oxygen and blood product transfusions. Further testing with sputum and blood cultures was planned.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 7

    MORNING REPORT October, 21 2013

    Dr. Rahmilna

    1. Jawanis , female, 73 yo, HCU


    CC: fever since 1 day ago Present Illness History:
    Fever since 1 day ago, high fever, no chill, no sweat Pale since 1 month ago Fatique since 1 month ago Cough since 4 days ago, dry cough, blood (-)

    Patient has been known anemia aplasia and got

    methylprednisolon 12-12-12 mg Red spot on skin since 1 month ago Bleeding history (-)

    Nausea and vomite (-) Mixturation normal Black stool (-), defecation normal

    Physical Examination
    GA:moderate Consc:cmc BP:110/60 Pulse:

    130x/m RR 28x/m T: 39,5C Skin: ptechie (+) Eyes: anemic (+), icteric (-) Lung: bronchivesiculer, Rh+/+ wet smooth high pitch on both basal lung, Wh-/Cor: normal Abd: normal Ext: Rf +/+, Rp -/-, oedem (-/-)

    Lab

    Hb: 4,8 g/dl Leu: 900/mm3 Ht: 14% Tromb: 2.000/mm3 Na/K/Cl: 129/3,2/98 mmol/L Ur/Cr: 35/0,7 mg/dl

    WD/:
    Septic ec bronchopneumonia (CAP) Pansitopenia ec anemia aplasia

    Therapy: rest/ soft diet/ O2 5L/mnt IVFD NaCl 0,9% 6 hour/kolf Ceftazidine 2x1 gr IV Levofloxacin 1x500 mg IV Methylprednisolon 2x62,5 mg IV Paracetamol 3x500 mg PRC and trombocyte transfussion

    Planning: culture sputum Culture blood

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