Morning Report Friday, February 22nd, 2013 Moderator: Physician In Charge: IA: dr.Hengki, dr.Asri,dr.Ali IB: dr.Nanik, dr.

Ames II : dr.Vindriya III: dr.Niniek B., Sp.PD-KPTI Summary Of Database: Mrs. Sri Bawon/29 y.o/w.29 Chief Complain: Shortness of breath The patient suffered from shortness of breath since a month before admission, didnt relieved by rest, worsen by activities. The patient complained cough with yellowish sputum since a month ago. Cold sweating intermittently since a month before admission. Decrease of body weight: 11 kg for a month. Fever intermittently, gradually onset, since a month before admission. Whitish tongue since 2 month before admission. Decrease of appetite since 1,5 months before admission. History of therapy: hospitalized in Lawang Medika Hospital for 2 days with diagnosis HIV and lung infection, drugs ?. History past illness (-) & family illness (-) History of marriage: divorced with her husband 1,5 years ago because her husband as sailor and had sex multiple partner. History of IVDU (-), free sex (-) Physical Examination: GA :Look severely ill; GCS 456 BP : 105/70 mmHg PR: 132 bpm regular weak Tax: 39,1C Head Neck Chest Cor

RR: 44x/mnt tachypneu

: an (-), ict (-), oral thrush (+) : Lymphadenopathy (-) JVP R+2cmH2O 30o position : : Ictus invisible & palpable at MCL S ICS V LHM ~ ictus RHM: SL dextra S1 S2 single, murmur (-) Pulmo : symmetric; SF D=S

S S S S S S

V V BV BV BV BV

Rh - - Wh - ++ ++ ++ ++

Abdomen : soefl, BS (+) N, tenderness (-), liver span 12 cm, troube space tympani, shifting dullness (-), hepatojugular reflux (-) Extremity : warm, edema (+), PPE Laboratory Findings Leukocyte Hb MCV/MCH Hematocrite Thrombocyte Eos/Bas/Neu/Lim/Mono Lymphocyte LED RBG Ureum Creatinine SGOT SGPT Natrium Kalium Chloride Albumin Determinant

: 7.40/mm3 : 13,1 g/dl : 80,3/28,3 : 40,6 % : 190.000/mm3 : 1,3/0,1/87,9/6,3/4,4 : 486/mm3 : 63 mm/h : 107 g/dL : 14,4 : 0,53 : 19 :3 : 140 : 3,17 : 109 : 2,27 : (+)

BGA pH : 7,49 pCO2 : 42,2 pO2 : 65,1 HCO3 : 31,3 BE : 8,4 Sat O2 : 94,2 Conclusion: Alkalosis Metabolic with Hypoxemia Moderate ECG Sinus rythm with heart rate 144 bpm Frontal axis :N Horizontal axis :N PR interval : 0,12 QRS complex : 0,08 QT interval : 0,32 Conclusion: sinus rhythm HR 144 bpm CXR

AP position, symmetric, less inspiration, too strong KV Soft tissue and bone: normal Trachea in the middle Phrenico-costalis angle dextra and sinistra: sharp Hemidiaphragm dextra & sinistra dome-shaped Lung: infiltrate at all area of lung D & S Cor site, shape, normal, size CTR 52% Conclusion: Lung TB Milier dd Pneumonia CAP
Cue & Clue Female/29yo SOB Fever intermittently Whitish tongue Cold sweating Decrease of BW & appetite BP:105/70mmHg PR: 132 bpm regular RR: 44tpm Tax: 39,1 Rh (+) BGA: alkalosis metabolic with hypoxemia moderate CXR: Lung TB milier dd Pneumonia Female/29yo SOB Fever intermittently BP:105/70mmHg PR: 132 bpm regular RR: 44tpm Tax: 39,1 Rh (+) Lymphocyte: 486 BGA: alkalosis metabolic with hypoxemia moderate ECG: sinus tachycardia CXR: Lung TB milier dd Pneumonia Female/29yo SOB Fever intermittently Whitish tongue Cold sweating Decrease of BW & appetite Multiple sex partner of her ex-husband BP:105/70mmHg PR: 132 bpm regular RR: 44tpm Tax: 39,1 PL 1. SOB IDx 1.1. Lung TB Milier 1.2. Pneumonia CAP PDx PTx Sputum O2 8-10 L/m culture, NRBM sensitivity test, & gram staining AFBS CD4 VDRL, TPHA, TB ICT, HBsAg, Anti HCV PMo S,VS,CB C/ 24h

2. Septic Condition

2.1. Lung Infection 2.2. UTI

UL, Sputum culture, sensitivity test, & gram staining

O2 8-10 L/m NRBM IVFD NS:D5 30dpm Paracetamol 3x500mg po

S, VS

3. HIV st III

AFBS O2 8-10 L/m CD4 NRBM VDRL, Soft Diet HCHP TPHA, TB 2100 kcal/d + ICT, extract kutuk fish HBsAg, Anti HCV IVFD NS:D5 30dpm Inj Ranitidin 2x50mg IV Paracetamol

Rh (+) PPE Lymphocyte: 486 Determinant test: (+) CXR: Lung TB milier dd Pneumonia Female/29yo Albumin: 2,27

3x500mg po Cotrimoxazole 1x960mg po Nystatin drop 4x1cc po 4. Hypoalbumi nemia Soft Diet HCHP 2100 kcal/d + extract kutuk fish Alb

Female/29yo SOB BGA: alkalosis metabolic with hypoxemia moderate

5. Alkalosis Metabolic with Hypoxemia Moderate

5.1. dt no 1

O2 8-10 L/m NRBM Consult Pulmonology Departement

S, VS, BGA