Duty Report

june 16th , 2017

ivo g, female, 33 y.o, FW-16
Cc: fever since 5 days ago

Present Illness History

fever since 5 days ago, high, no chill, no sweat
decrease of bodyweight since 1 month ago, unknown
decrease of appetite since 1 month ago
Pale since 2 weeks ago
fatique since 10 days ago
cough since 1 week ago, purulent, blood(-)
History of bleeding(-)
Patient has been known suffer myoma uteri and going to
laparotomy but patient refused
patient has been hospitalized before at RS bhayangkara and got
blood transfussion 5 times
Physical Examination
 Consciousness level: cmc

 BP : 120/80mmHg

 HR : 92x/minute

 RR : 22x/minute

 T: 37,5 C
 Eye
◦ Conjunctiva are anemic +
◦ Sclera are icteric -

 Neck
◦ JVP 5-2 cmH20
◦ Thyroid unpalpable

 Lung:
◦ Inspection: symmetric static and dinamic
◦ Palpation: fremitus simetric
◦ Percussion: sonor
◦ Auscultation: broncovesicular, rales +/+, wheezing -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS ICS V
◦ Percussion:
 Left border: ictus is palpated at 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: pure rhythm, no murmur, M1>M2, P2 < A2
 Abdomen:
◦ Inspection: enlargement (+)
◦ Palpation: liver and spleen aren’t palpable, a mass with
diameter 10 cm, hard, pain(-) at regio suprapubic
◦ Percussion: tympani, shifting dullness (-)
◦ Auscultation: bowel sound (+) normal

 Extremities:
◦ Oedema -/-
◦ Physiologic Reflex +/+
◦ Pathologic Reflex -/-
Laboratory
Hb 5.0 gr/dl
Ht 16
WBC 9.680
platelet 274.000
Ur/Cr 151/9.7
MCH/MCV/MCHC 26/81/32
Working Diagnose
 CAP
 mild anemia microcytic hypochrome ec
chronic disease
 myoma uteri
Therapy
 Rest/ regular diet high calori high protein
 IVFD NaCl 0,9% 500 cc/8h
 cefriaxone inj 1x2 g iv
 PCT 3x500 mg
 NAC 3x200 mg