DUTY REPORT

01st MARCH, 2015

GP on duty:
dr. Ruben

Coass on duty:
Aris
zikril
 PATIENT RECAPITULATION
3rd Floor: Mrs. R, 55 yo., icterus suspect hepatitis
4th Floor : -
5 th Floor:
Mrs. N, 57 yo. CKD st. v + hypoglikemia on dm type II
Mrs. R, 47 yo. UTI + dyspepsia and low intake
6th Floor :
 PATIENTS IDENTITY
Name : Mrs. S
MR no : 801983
Sex : Female
Age : 62 years old
Religion : Moeslem
Marital Status : Married
Ethnic : JAVA
Address : Bukit duri tanjakan I no. 28 Rt
09/12, tebet
 ANAMNESIS
Autoanamnesa on 01st march 2015 at
21.30 PM

Chief Complaint : Patient came with

complaint of weakness 4 day before
admission

Additional Complain: dizzziness (+) and

loss of appetite (+)
Present History
 Present History
limp felt since 4 days before admission.
weakness accompanied by dizziness and
sway. . The last four years of blood out of a
lump when rubbed , bleeding become
heavy since the last 4 days, with 500 cc
per day. this morning checking hb rate of
his patients in a health center 7.5 g / dl.
patients admitted to having a lump in the
right breast since 2006, initially only of
green beans, but increasingly enlarged.
This last week of blood out continuously
and decreased appetite, eating only 5
 Family Illness
Aunt and sister of patient had been
diagnosed with breast tumor.
Diabetes Mellitus (-)
Hypertension (-)
Heart disease (-)
 HABITS AND LIFESTYLE
Smoked (-)
NAPZA (-)
 PHYSICAL EXAMINATION
VITAL SIGNS
General State : Moderate Illness
Consciousness : Compos Mentis
Blood Pressure : 130/70 mmHg
Heart rate : 100 x/minute
Respiratory Rate : 20 x/minute
Temperature : 37,1 oC
Body Weight : 50 kg
Body Height : 155 cm
BMI : 25 (overweight)
 PHYSICAL EXAMINATION
General Examination
Head : Normocephal
Eye : anemic conjunctiva (+/+), icteric sclera
(-/-)
Ears : normotia, discharge (-)
Nose: septum deviation (-), discharge (-)
Mouth : oral trush (-), leukoplakia (-)

Neck : lymph nodes enlargement (-), JVP 5 2

cmH2o
axillary nodes: lymph nodes enlargement (+)
Thorac and breast : breast tumor dextra, size 10x15
cm, soft consistency, demarcated
COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis
dekstra
Left border: ICS V, linea midclavicularis
sinistra
Heart waist: ICS IV, linea parasternal sinistra
Auscultation : regular 1st and 2nd heart
sound, murmur (-), gallop (-)
PULMO
Inspection : chest within normal shape,
symmetries on static and dynamic
state
Palpation : tactile vocal fremitus both
lungs were symmetries.
Percussion : resonant both lungs
Auscultation : Vesicular Breath Sound +/
+, rales -/-, wheezing -/-
Abdomen : tenderness (-), intestinal
motility (n)
Extremities: pitting edema -/-, CRT <
2
 Laboratory Results
LABORATORIUM

RESULT NORMAL RANGE

Hematologi rutin:
Hb 7,0** 13 - 18 g/dl
Ht 23** 40 52 %
Erythrocyte 2.9* 4.3 - 6.0 mil /ul
Leukocyte 11740* 4800 - 10800/ul
Thrombocyte 561000* 150000 - 400000/ul
MCV 78* 80 96 fL
MCH 24* 27 - 32 pg
MCHC 31 32 36 g/dL
 RESULT NORMAL RANGE

Kimia klinik:
Ureum 23 20 - 50 mg/dl
Kreatinin 0,8 0.5 1.5 mg/dl
Blood Sugar 103 < 140 mg/dl
Natrium 136 135 147 mmol/L
Kalium 3,1 3.5 5.0 mmol/L
Klorida 103 95 105 mmol/L
 RESUME
Anamnesis:
limp felt since 4 days before admission.
weakness accompanied by dizziness and
sway. . The last four years of blood out of
a lump when rubbed , bleeding become
heavy since the last 4 days, with 500 cc
per day. this morning checking hb rate of
his patients in a health center 7.5 g / dl.
patients admitted to having a lump in the
right breast since 2006, initially only of
green beans, but increasingly enlarged.
This last week of blood out continuously and
decreased appetite. perceived body weight
decreased since last 4 months. patients
undergoing treatment during this just
acupuncture.

Physical Examination:

Anemic conjuntiva +/+ ,

breast tumor dextra
Laboratory Results :
Hb 7,0 , Ht 23,Erythrocyte 2.9
,Leukocyte 11740 ,Thrombocyte
561000
 PROBLEMS LIST

1. Anemia ec bleeding
2. Ca mamae
3. Dyspepsia low intake
 Problem Analysis
I. Anemia ec bleeding

Anamnesis : weakness (+) and This past week the

patient said continous blood out of lump. bleeding
become heavy since the last 4 days, with 500 cc
per day.
PE : Conjunctiva anemic +/+
Lab : hb 7,0 mg/dl
Plan of Diagnostic : Check SI , TIBC Feritin,
PT / APTT
Plan of Theraphy:
- Tranfusi PRC 600 cc
- Transamin
 II. Ca mamae

Anamnesis : The patient also had a history of lump in

the right breast since 2006. initially only of green
beans, but increasingly enlarged until now. patients
undergoing treatment during this just acupuncture
patient denies the existence of joint pain or bone pain,
no tightness and pain in the head.
PE : there is a lump in her breast, size 10x15 cm, soft
consistency, demarcated
Lab : Leukocytosis (11
Planning : CT scan of the head, USG, biopsy
 III. Dyspepsia low intake

Anamnesis dizzziness & loss of appetite

PE teeth date, only 2 front teeth and below
so that patients feel a decrease in appetite.
Planning of therapy
1. Soft diet 1700kkal
2. Ranitidin 2x1 amp
3. Ondancetrone 3x4 gr
 PROGNOSIS

Quo ad vitam : Dubia ad malam

Quo ad sanationam : Dubia ad malam
Quo ad functionam : Dubia ad malam
THANK YOU