Duty report

August 8th , 2016

Rahadian, Male, 31yo, mw 8

Chiefcomplaint
Paleness since 1 week ago
Present illness history
Paleness since 1 week ago
fatique since one week ago, especially felt
during activity
Dizziness since 1 day ago
Fever 2 weeks ago, not high, not chill, not
sweating a lot. But now fever (-)
Decreased appetite (-)
Cough since 1 months ago, sputum (+)
Nausea and vomiting (-)
Mixturation yellow, pain when mixturation
(-). mixturation reddish (-).
Physical Examination

Consciousness level: CMC

BP : 120 / 70 mmHg

HR : 87 x/minute

RR : 19 x/minute

T: 37 C
Eye
Conjunctiva anemic +/+
Sclera icteric -/-

Neck
JVP 5 - 2 cmH20

Lung:
Inspection: simetris sinistra = dextra
Palpation: fremitus sinistra = dextra
Percussion : sonor
Auscultation: Vesicular, Rh - /-, wh - /-
Cor:
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: RIC II
Auscultation: pure rhythm, murmur (-)
Abdomen:
Inspection: enlargement (-)
Palpation: hepar and spleen not palpable
Percusion : tympani
Auscultation: bowel sound (+) normal

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory
Keterangan Nilai
Hb 7,0 g/dl
Leukosit 17.800 /mm
Ht 23 %
Trombosit 208.000 /mm3

02/12/17
Working Diagnose
Paroxysmal nocturnal
hemoglobinuria
Moderate Anemia normocytic
normochrom cb hemolytic cb
autoimun
Chronic bronkitis
Therapy
rest / daily diet
IVFD NaCl 0.9% 12 hours / kolf
Cefoperazone 2 x 1 gr
Methylprednisolone 16 mg - 16 mg - 16 mg
Imuran 1 x 50 mg
Lansoprazole 1 x 30 mg
NTR 2 x 1
N. Acetil sistein 3 x 200 mg
Paracetamol 3 x500 mg