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    Duty Report Friday, 2 August 2019

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    Haris
    1. Dr. Haris, Dr. Adit, Dr. Dimas, Dr. Angel, and Dr. Ferdi were the physicians in charge in internal medicine. Dr. Adinda, Dr. Kasman were in consult, Dr. Ajeng was in HCU, and Dr. Arum, Dr. Galih were in UGD. Dr. Nadina was the chief on duty and Dr. Fatma Sp.PD KGer was the consultant. 2. Mr. J, a 50-year-old man in Ward 22, presented with a neck bump for 1 year that had been growing for 3 months. On examination, he had an immobile

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    Duty Report Friday, 2 August 2019

    Uploaded by

    Haris
    35 views4 pages
    1. Dr. Haris, Dr. Adit, Dr. Dimas, Dr. Angel, and Dr. Ferdi were the physicians in charge in internal medicine. Dr. Adinda, Dr. Kasman were in consult, Dr. Ajeng was in HCU, and Dr. Arum, Dr. Galih were in UGD. Dr. Nadina was the chief on duty and Dr. Fatma Sp.PD KGer was the consultant. 2. Mr. J, a 50-year-old man in Ward 22, presented with a neck bump for 1 year that had been growing for 3 months. On examination, he had an immobile

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    1. Dr. Haris, Dr. Adit, Dr. Dimas, Dr. Angel, and Dr. Ferdi were the physicians in charge in internal medicine. Dr. Adinda, Dr. Kasman were in consult, Dr. Ajeng was in HCU, and Dr. Arum, Dr. Galih were in UGD. Dr. Nadina was the chief on duty and Dr. Fatma Sp.PD KGer was the consultant. 2. Mr. J, a 50-year-old man in Ward 22, presented with a neck bump for 1 year that had been growing for 3 months. On examination, he had an immobile

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    35 views4 pages

    Duty Report Friday, 2 August 2019

    Uploaded by

    Haris
    1. Dr. Haris, Dr. Adit, Dr. Dimas, Dr. Angel, and Dr. Ferdi were the physicians in charge in internal medicine. Dr. Adinda, Dr. Kasman were in consult, Dr. Ajeng was in HCU, and Dr. Arum, Dr. Galih were in UGD. Dr. Nadina was the chief on duty and Dr. Fatma Sp.PD KGer was the consultant. 2. Mr. J, a 50-year-old man in Ward 22, presented with a neck bump for 1 year that had been growing for 3 months. On examination, he had an immobile

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Duty Report

    Friday, 2 August 2019

    Physician in charge:
    IA : dr Haris, dr. Adit, dr. Dimas, dr. Angel, dr. Ferdi
    II :
    Consult : dr Adinda, dr Kasman
    HCU : dr Ajeng
    UGD : dr Arum, dr Galih
    Chief On Duty : dr Nadina
    Consultant : dr. Fatma Sp.PD KGer

    Summary of Database:
    Mr. J / 50 yo / Ward 22

    Chief complaint: Bump Neck

    Anamnese
    Patient came to RSSA with chief complained neck bump since 1 year ago disappear arise without apparent
    cause, and getting bigger since 3 month, rounded lump with hard consistency, immobile, and also with pain.
    He also complain about hard to swallow since 2 days before admission, feels like there is mass in the neck
    that push the throat, and also pain in the right head, feel like being stabbed.

    Physical Examination
    General appearance = looked moderately ill GCS 456
    BP = 140/90 mmHg PR = 78 bpm RR 20 = 24 Tax : 36,7°C
    tpm

    Head Pale conjunctiva (-) Icteric sclera (-),


    Neck JVP R+2 cmH2O (30/45 degree), lymphnode enlargement (-)
    Chest
    Heart: Ictus palpable at ICS V 2cm lateral MCL S
    LHM ≈ ictus // RHM: SL D
    S1, S2 single, murmur (-) gallop (-)
    Lung: Symmetric, SF D=S,
    Percusion: S S V V Rh - - Wh - -
    S S V V - - - -
    S S V V - - - -
    Abdomen Soefl, bowel sound (+) normal
    liver span 10 cm, unpalpable
    traube space thympani
    Extremities Warm akral, CRT<2, edema -

    1
    Laboratory Findings (02/08/2019)

    Lab Value (Normal) Lab Value (Normal)

    Haemoglobine 11,20 11,4 -15,1 g/dl Natrium 135 136-145


    mmol/L

    Leukocyte 16,910 4.700 – 11.300/µL Kalium 3,55 3,5-5,0 mmol/L

    Hematocrit 33,79 38 - 42% Chlorida 103 98-106 mmol/L

    Trombocyte 640.000 142.000– 424.000 SGOT - 0-40


    /µL

    MCV 71,10 80-93 fl SGPT 0-41

    MCH 23,60 27-31 pg HBsAG -

    Eo/Bas/Neu/limf/ 1,6/0,7/75, 0-4/0-1/51-67/25- Bil T/D/I - <1 / <0.25 / <0.75


    Mon 9/15,3/6,5 33/2-5

    PPT 10.5 Ur 28,30 16.6 – 48.5

    APTT 25.1 Cr 1.07 <1.2

    INR

    2
    CUE AND CLUE PL IDx PDx PTx PMo and
    PEdu

    Mr J/ 50 yo 1. Tumor Colli 1.1 metastase FNAB • Diet lunak TKTP Subjective


    dextra proses dt KNF Biopsi 2100 kkal/hari GCS,
    Subjective 1.2 Limphoma
    neck bump since 1 year ago disappear arise without • IVFD NS
    apparent cause, and getting bigger since 3 month, 1500cc/24jam
    rounded lump with hard consistency, immobile, and
    also with pain • PO Codein 3x20

    Objective • Paracetamol 3x500


    Reg Colli D :
    I : Solid mass, single
    P : immobile, hard consistency

    Mr J/ 50 yo 2. HT Urgency 2.1 primary PO Amlodipin 1x10mg Subjectiv


    2.2 secondary
    Subjective PO Lisinopril 1x10mg VS
    pain in the right head, feel like being stabbed

    objective
    TD 140/90
    N 78x/mnt

    TD 220/140 when in emergency room

    Mr J/ 50 yo 3 moderate PO Codein 3x20mg


    cancer pain
    Subjective Paracetamol
    neck bump since 1 year ago disappear arise without 3x500mg
    3
    apparent cause, and getting bigger since 3 month,
    rounded lump with hard consistency, immobile, and
    also with pain
    Had before drug family

    Objective
    VAS 4/10
    Mr j / 50 Yo 3. Trombositosi 3.1 Paraneoplastic Treat underlying disease Subjectiv, VS
    s syndrome
    Lab 3.2 essensial
    640.000

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