Duty report

October 24th, 2016

Suyatno, Male, 42yo,

Chief complain
Fever increased since 7 days ago
 Present illness history
Fever increased since 7 days ago. Actually felt since 3
weeks ago. Intermittent fever, not high, and not
shivering.
Cough since 6 months ago. Sputum (+) blood (-)
Weight loss since 3 weeks ago approximately 10 kg
Decreased appetite since 3 weeks ago
Nausea since 3 weeks ago, vomit (-)
Liquid defecation since three weeks ago with a
frequency of 4-5 x / day with the number of cup.
Urination no complaints
A history of night sweats since 6 months ago
History tattoo (+)

06/12/2017
Physical Examination
level of consciousness : CMC

BP : 100 / 60 mmHg

HR : 72 x/minute

RR : 24 x/minute

T: 37,5 oC
 Eye
Conjunctiva are anemic +/+
Sclera icteric -/-

Neck
JVP 5- 2 cmH20

Lung:
Inspection: simetric left = right
Palpation: fremitus left = right
Percussion: sonor
Auscultation: Bronchovesicular, Rh +/+, Wh -/-

Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger medial LMCS RIC V
Percussion:
Left border: 1 finger medial LMCS RIC V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: Pure rhythm, noisy (-)
 Abdomen:
Inspection: Enlargement (-)
Palpation: liver palpable 2 finger uac and 2 finger upx,
rubbery anf flat surface and spleen not palpable
Percussion: tympani
Auscultation: bowel sound (+) normal

Spine:
Pain of word -/-
Tenderness -/-

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory

Hb 8,1 gr / dl
Leukosit 5.860 / mm3
Ht 24 %
Trombosit 179.000 / mm3
Ur / Cr 27 / 0,8
Na / K / Cl 129 / 2,8 / 100
GDS 111
SGPT / SGOT 340 / 368

06/12/2017
06/12/2017
Working Diagnose
HIV AIDS with :
chronic dirrhea
Lung TBC
Oral candidiasis
Mild anemia normositik normokrom cb
chronis disease
Hyponatremia et hypokalemia cb low
intake
Acute Hepatitis cb viral
Therapy
rest / soft diet low fibre
IVFD Nacl 0, 9% 8 hours / kolf
Paracetamol 3 x 500 mg
N-cysteine Acetil 3 x 200 mg
Cotrimoxazole 1 x 960 mg
Fluconazole 1 x 150 mg
KSR 2 x 1

06/12/2017
planning
Rapid test
Hepatitis marker
USG abdomen
BTA I,II, III
Expertise ronthgen thoraks

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