duty report, Januari 22- 2014.ppt

DUTY REPORT JANUARY 22TH 2014

ZULKIPLI,MALE, 17 YO ( MW-03)Cc : Swelling on the left knee 1 week ago

Present illness history : Swelling on the left knee 1 week ago, slowly

starting, pain (+), pain was increased if activity, pain was decreased if rest, injury (-)

Patient’s had been knew suffer Hhemophilia A since 1 year ago, and had been checked Factor VIII as number 3%, and get therapy koate 1800 IU

Fever was denied History of gum bleeding (-), epistaksis (-) Mixturation and Defecation were normal

Past Illness History :o History of bleeding long cloth

Family Illness History :o There is no families of patient have illness like this

Vital Sign :Consc : CMCBP : 100/60 mmHg HR : 72x/’ RR : 18x/’ T : 36,5 ‘CHeigt : 156 cmWeigh: 45 kgBMI : 18,4 kg/cm2

Phsycal examination :Eye : Conjuctiva not anemic,sclera not ictericMouth : Papil atrophy (-), Gingiva Hypertrophy (-)Neck : JVP 5-2cmH2OLung : I: simetris right=left ststis and dinamis

P: fremitus right=left P: sonor A: vesikuler, rales (-/-), Whezzing (-/-)

Heart : I: Ictus cordis unseen P:Ictus was palpable 1 finger medial of

LMCS RIC V P: left=1 finger medial of LMCS RIC V,

right:LSD Upper=RIC II, waist of heart (+) A: reguller, murmur (-), M1>M2, P2<A2

Abdoment :

I : not seen bulgeP: Liver and spleen not palpableP: timpaniA: bowel sound (+) N

Extremitas : Fisiology reflex :(+)/(+) Normal Pathology reflex:(-)/(-) Normal

Regio left knee : swelling size (7x5x2) cm, hard consist, flate of surface, immobile, pain (+)

Laboratory:Hb : 14,5 gr/dlLeu : 7.200/mm3Ht : 43% Platelet : 178.000/mm3PT : 12,1 sAPTT : 0

WD/: Hemoarthrosis ec Hemophilia A

Thy : Rest/ daily diet Tramadol 3x50 mg if needed Koate 1800 IU

SITI JAUHARI,FEMALE, 61 YO ( TI)Cc : Fever since 6 days agoPresent illness history : Fever since 6 days ago , continously, sweat (+), tremble(+) Cough since 6 days ago, mucous (+), white, blood (-) Nausea and vomite since 3 days ago, frequency > 3x,

volume ¼ glass Pain of bladder since 3 days ago, uncontinously, no referred

pain, Headache since 3 days ago, Patient had been hypertension since 5 years ago, not

reguller control, Apetite was usuall Nausea and vomite was denied Mixturation and defecation were normal

Past Illness History :o There is no history of illness like thiso History of Diabetes melitus was deniedo History of heart disease was deniedo History of asthma was denied Family Illness History :o There is no families of patient have illness like thisVital Sign :Consc : CMCBP : 150/90 mmHg HR : 104x/’ RR : 24x/’ T : 39 ‘CWeigh : 70 kgHeight : 155 cm

Phsycal examination :Eye : Conjuctiva not anemic,sclera not ictericNeck : JVP 5-2cmH2OLung : I: simetris right=left ststis and dinamis

P: fremitus right=left P: sonor A: vesikuler, rales (-/-), Whezzing (-/-)

Heart : I: Ictus cordis unseen P:Ictus was palpable 1 finger medial of

LMCS RIC V P: left=1 finger medial of LMCS RIC V,

right:LSD Upper=RIC II A: reguller, murmur (-), M1>M2, P2<A2

Abdomen:

I : not seen bulgeP: Liver and spleen not palpable, tenderness of

bladder (+)P: timpaniA: bowel sound (+) NExt : Fisiology reflex :(+)/(+) Normal

Pathology reflex:(-)/(-) Normal Edem (-)/(-)

Laboratory:Hb :12,8 gr/dlLeu : 7.500/mm3Ht : 38% Platelet : 304.000/mm3Malaria : (-)Proteinuria : (-)WD/: Malaria

DD/ Urinary tractus infection (acute cystitis)

o Stage II hypertension ec essensial

Thy : Rest/ Low salt diet II IVFD NaCl 0,9% 12 hours/kolf Paracetamol 3x500mg Amlodipin 1x 5 mg Domperidon 3x10 mg

Planning: MalariaRenal function testLipid profileOpthalmologist consultation