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  • Duty Report DR Rasyid, en

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    This document summarizes a medical report for a 32-year-old female patient who presented with increased coughing and yellow phlegm over the past 2 weeks. On physical examination, the patient showed signs of oral candidiasis, anemia, and pneumonia in the left lower lung lobe. Laboratory tests found low hemoglobin and platelet counts. The working diagnoses were AIDS, oral candidiasis, community-acquired pneumonia, and mild anemia of chronic disease. The patient was prescribed IV fluids, antibiotics, antifungals, and supportive medications.

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    Duty Report Dr Rasyid, En

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    This document summarizes a medical report for a 32-year-old female patient who presented with increased coughing and yellow phlegm over the past 2 weeks. On physical examination, the patient showed signs of oral candidiasis, anemia, and pneumonia in the left lower lung lobe. Laboratory tests found low hemoglobin and platelet counts. The working diagnoses were AIDS, oral candidiasis, community-acquired pneumonia, and mild anemia of chronic disease. The patient was prescribed IV fluids, antibiotics, antifungals, and supportive medications.

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    7 views13 pages

    Duty Report DR Rasyid, en

    Uploaded by

    Anonymous C7LSjf
    This document summarizes a medical report for a 32-year-old female patient who presented with increased coughing and yellow phlegm over the past 2 weeks. On physical examination, the patient showed signs of oral candidiasis, anemia, and pneumonia in the left lower lung lobe. Laboratory tests found low hemoglobin and platelet counts. The working diagnoses were AIDS, oral candidiasis, community-acquired pneumonia, and mild anemia of chronic disease. The patient was prescribed IV fluids, antibiotics, antifungals, and supportive medications.

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    © All Rights Reserved
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    of 13

    March14th , 2018

    DUTY REPORT
    EN, 32 YO, FEMALE, FW 02
     Chief Complaint:
     Cough increases since 2 weeks ago
     Present Illness History
     Cough increases since 2 weeks ago, with yellowish phlegm, no bloody
    cough, patient had cough since 1 year ago.
     No shortness of breath
     Decrease of body weight since 1 month ago, weight loss ± 3 kg in a month
     Decrease of appetite since 1 month ago, with intake only 2-3 tablespoon in
    each meal
     Nausea (+), vomit (-)
     Stomatitis come and go in different locations since 1 month ago
     White tongue since 1 month ago
     Pain when swallowing since 1 month ago
     Headache since 1 day ago, headache felt on all parts of head, no pulsatile
    headache.
     Patient was sent from Naili Hospital with AIDS and seeking for more
    advanced therapy
     Micturation in nirmal limits
     Defecation in normal limits
    Past illness history
     Patient has been hospitalized because headache and
    cough in RST, with negative sputum exam
    PHYSICAL EXAMINATION
     Consciousness level: CM

     BP : 110/70 mmHg

     HR : 100 x/minute

     RR : 24 x/minute

     T: 36,6 C
     Eye
     Anemic conjunctiva (+)
     Icteric sclera(-)
     Neck
     JVP 5-2 cmH20
     No lymph enlargement
    Lung:
     Inspection: statically & dynamically symmetric sin=dextra
     Palpation: fremitus weakened on the left lower lobe
     Percussion: dull in the left lower lobe
     Auscultation: bronchovesicular, rales +/+, wheezing -/-

     Cor:
     Inspection: ictus is not seen.
     Palpation: ictus is palpated at 1 fingermedial LMCS ICS V
     Percussion:
     Left border: 1 finger medial LMCS ICS V
     Right border: linea sternalis dextra
     Upper border: ICS II
     Auscultation: regular, murmur (-)
     Abdomen:
     Inspection: enlargement (-)
     Palpation: no enlargement
     Percussion: tympani
     Auscultation: bowel sound (+) N

     Extremities:
     Oedema pretibia -/-
     Physiologic Reflex +/+
     Pathologic Reflex -/-
    LABORATORY

    Hb 9,3 gr/dl

    Ht 36

    WBC 3910/Mm3

    Platelet 169.000/Mm3

    Na/K/Cl 9,4/141/4,1/106

    Ur/Cr 16/0,6
    GDS 102
    MCV/MCH/MCHC 84/26/31
    WORKING DIAGNOSE

     AIDS
     Oral Candidiasis

     Community Acquired Pneumonia

     Mild Normocytic Normochrome Anemia ec


    chronic disease
     Lung Tuberculosis
    THERAPY
     Rest/ ML Diet high calorie high protein
     IVFD NaCl 0,9% 8 hrs/kolf

     Inj. Ceftriaxone 2x1 gr

     Cotrimoxazole 1x960

     N-Acetylsistein 2x200 mg

     Paracetamol 3x500 mg

     Nystatin drop 4x 5 gtt

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