Laporan Jaga Bangsal Rabu, 17 Feb 2016

8/18/2019 Laporan Jaga Bangsal Rabu, 17 Feb 2016

1/18

Duty Report

17 February 2016Resident on duty: dr. Shiddiq & dr. Agil

o!ass on duty: "andelia & #i$i Sil%a


2/18

atients Re'apitulation

• (s. R)* 2+ y,o* )-

• (rs. SS* / y,o* aneia* 'olitis ineti

• (r. R *aneia* 3"4

• (r. S* 72 y,o* dyspepsia* A5) superiposeon 5D* blood strea e.' suspe't throatirritation

• (rs.* obs.dyspnea• (rs.* D"F

• (r. * aneia* hepatoa


3/18

atient )dentity

• 3ae:R)

• Se: Feale

• (R: 81

• Age:2+ years old

• Religion: (osle

• (arital status: Single

• Adress: l. Dr ro Satrio 99 -iong 3o +

• Date o adission : 17 February 2016


4/18

"istory -aing

• Autoananesis on 17th February2016 at / p.

• hie oplaint: gu bleeding or 2days


5/18

"istory o resent )llness

atient 'ae to the ;ard ;ith 'hie 'oplaint oha$ing gu bleeding or 2 days. atient also'oplaining about bruise on her right lo;er ar* righttight* and right 'al. She state that this syptos

o''ur ;hen she eels tired. ?.

atient ;as diagnosed ;ith )- 6 onths ago.

atient said that sin'e 6 onths ago she has prolongedenstrual 'y'le =10 days* pads@day* regular 'y'le?

atient 'onsued (etylprednisolon 2 g or thisillness* but the dose ;as redu'ed to / g 1 ;eeago ;hile ha$ing onthly 'he' up.


6/18

"istory o ast )llness

)-* no history o diabetes* hypertension*idney* heart* and lung diseases

• Faily history illness:

3o aily ebers ha$ethe siilarsyptos

3o history o diabetes* hypertension*idney* heart* and lung disease


7/18

hysi'al eaination

• 9eneral state : ild illness

• on'iousness: Fully alert

• #ital sign

– lood pressure: 110@80 "g

– ulse: 72 bp* regular

– Respiratory rate: 1+ ties@inutes

– -eperature: 6*10

– ody ;eight: 71 g

– ody height: 161 '

– (): 27*+


8/18

9eneral status

•"ead : 3oro'ephal* oon a'e

Bye : pale 'onCun'ti$a =!@!?* i'teri' s'lera =!@!?

Bars : dis'harge =!?

3ose : septu de$iation =!?* dis'harge =!?

(outh : 'oated tongue =!?* hyperei' pharyn =!?*

noral -1!-1* pale outh u'osa =!?* dried

u'osa =!?* gu bleeding =>?

•3e' : # !2* lyph nodes enlargeent =!?


9/18

• -hora: syetri'* inter'ostals retra'tion =!?

R

)nspe'tion: )'tus 'ordis =!?

alpation: hea$e =!?* lit =!?* thrill =!? er'ussion:

Right border: )S #* linea id'la$i'ularis detra

4et border : )S #* linea id'la$i'ularis sinistra

"eart ;aist: )S )#* linea parasternal sinistra

Aus'ultation : regular 1st and 2nd heart sound* urur

=!?* gallop =!?


10/18

–E4(

• )nspe'tion : 'hest ;ithin noral shape* syetri' on stati' and dynai' state

• alpation : ta'tile $o'al reitus both lungs ;ere syetri'* 'hest epansion

syetri'

• er'ussion : resonant both lungs

• Aus'ultation : $esi'ular breathing sounds* rales =!@!?* ;heeing =!@!?

• Abdoen : Gat* not distended

tipani* splenoegaly=!?* hepatorgaly =!?*

pain tenderness =!?• Btreities : ;ar* R- H 2 se'onds* bruise lo;er right ar* thigh* right 'al


11/18

4aboratoriu

4aboratoriutest

Result Normal Value

01.02.2016 17.02.2016

"eoglobin 12* 12*+ 1!18 g@d4

"eatorit + /2 /0 I 2 JBritrosit *7 6*2 /* I 6*0 Cuta@4

4euosit 1/7+0 +0 /800 I 10800

-robosit 18000 +000 =DE4? 10000 I/00000

(# 68 68 80 I +6 4(" 22 1 27 I 2 pg

(" 2 2 2 I 6 g@d4

RD< 1/*6 11*!1/* J


12/18

Laboratoriumtest

Result01.02.2016

Result17.02.2016

Normal value

Chemicalclinique

S9- =AS-? 16 H E@4

S9- =A4-? 2 H /0 E@4

aso%l 0 0 0!1J

eosino%l 0 0 1!J

bands 2!6J

segent 72 6 0!70J

lypho'yte 20 20!/0J

ono'yte 6 2!8J


13/18

RBSE(B

"istory taing : (s. R)* 2+ years old* 'ae to the ;ard ;ith'hie 'oplaint o ha$ing gu bleeding or 2 days. ruiseon her right lo;er ar* right tight* and right 'al.Syptos o''ur ;hen she eels tired. ?.

atient ;as diagnosed ;ith )- 6 onths ago. rolongedenstrual 'y'le =10 days* pads@day* regular 'y'le?

atient 'onsued (etylprednisolon 2 g or thisillness* but the dose ;as redu'ed to / g 1 ;ee ago;hile ha$ing onthly 'he' up.

hysi'al eaination :

outh: gu bleeding =>?

Btreity: bruise on lo;er right ar* thigh* right 'al

4aboratory results : trobo'yte +000


14/18

4ist o robles

• -hrobo'ytopenia

•

DD: – hroni' li$er diss

– 4eu'eia

– aplasti'

– )diopathi' -hrobo'ytopeni' urpura


15/18

Dis'ussion

"istory taing: gu bleeding =>?* bruise on herlo;er ar* right tight* and right 'al* ;eaness=>?* heada'he =>? and bloody stool =>?. atient;as diagnosed )- 6 onths ago and 'onsued

(etylprednisolon 2 g* but the dose ;asredu'ed / g 1 ;ee ago

hysi'al eaination : gu bleeding =>?* bruiselo;er right ar* thigh* right 'al =>?

4aboratory result : trobo'yte +000


16/18

lan and -reatent

• lan: – lood sear

– one (arro; un'ture

• -reatent: – -' transusion =preedi'ation: deaethasone?

– (etylprednisolon 2 g

–

epraole 1 /0 g – )npepsa 2 10 g

– a$it D 00 g

– ara'etaol 00 g =i needed?


17/18

rognosis

• Kuo ad #ita : dubia ad bona

• Kuo ad Fun'tiona : dubia ad bona

• Kuo ad Sanationa : dubia


18/18

Laporan Jaga Bangsal Rabu, 17 Feb 2016

Documents