DUTY REPORT

10th FEBRUARY 2016

RESIDENT ON DUTY:
- dr. PUTRI
- dr. AGILL

COASS ON DUTY:
- REZA
- OKI
Patient Recapitulation

1. Mr. S, 79 Y.O Anemia e.c, MDS, CHF, HT,

Pneumonia
2. Mr. R, Y.O Ca larynx, Increasing of
Transaminase enzyme, hipoalbuminemia,
hiponatremia
Patients Identity

Name :R
Date of Birth : 17/07/1940
Age : 75 y.o
Sex : Male
Religion : Moslem
Address : South Jakarta
Marital Status : Married
Med. Rec. No : 352546
Anamnesis

Alloanamnesis obtained by his daughter

Chief Complaint :
Abdominal Pain for 3 days
History of Present Illness
Patient came to the ward with abdominal
pain for 3 days, along with nausea but no
vomit.
He also felt general weakness. He hasnt gone
to any doctor to treat his complaint.
He was sent to internal medicine department
from ENT department because of increasing
SGOT and SGPT.
 Defecate and urinate within normal limit.
He said that he loss his voice 8 months ago
then he came to the doctor. He undergone CT
scan, bronchoscopy and biopsy. The result
was Larynx carcinoma.
2 months ago, he complained feeling out of
breath. He undergone tracheostomy and he
was assembled with a NGT by his
otolaryngologist.
History of Past Illness

DM (-)
HT (-)
Heart Disorder (-)
Kidney Disorder (-)
Allergy (-)
Family History

DM (-)
HT (-)
Heart Disorder (-)
Kidney Disorder (-)
Allergy (-)
Physical Examination
General State : Moderatly Ill
Conciousness : Compos Mentis

Vital Sign
- BP : 120/70 mmHg - RR : 20 tpm
- HR: 88 bpm, Reg - T : 36,5oC

Body Weight : 50 Kg
Body Height : 165 Cm
BMI : 18,37 Kg/m2 (Underweight)
 Head : Normocephal
Eye : Anemic Conjunctiva +/+, Icteric
Sclera -/-
Ears : Within Normal Limit
Nose : NGT (+)
Throat : -
Neck : Tracheostom (+)
 Thorax
- Pulmo
I : Normochest, chest retraction (-)
P : Vocal Fremitus within normal limit
P : Sonor
A : Vesicular +/+, Wheezing -/-, Rales -/-

- COR
I : Ictus Cordis was seen
P : Ictus Cordis was palpable on ICS V sinistra
midclavicula line
P : No cardiomegaly
A : Regular 1st and 2nd heart sound, Murmur (-),
gallop (-)
 Abdomen:
- I : Flat
- A : Bowel Sound (+)
- Pa : Tenderness (+) epigastric region, Liver
and Spleen enlargement (-)
- Pe : Tympani

Extremities : Warm, CRT < 2 sec, Edema (-),

Yellowish skin (-)
Lab Result
Lab Result
Normal value
examination (05/02/2016)
Haemoglobyn 10.8 13-18 g/dL
Hct 31 40-52 %
Eritrocyte 4.2 4,3-6,0 juta/L
Leukocyte 20890 4.800-10.800/L
Trombocyte 345000 150.000-400.000/L
MCV 74 80-96 fL
MCH 26 27-32 pg
MCHC 34 32-36 g/dL
 Result
Lab Examination Normal Value
(05/02/2016)
SGOT (AST) 100 < 35 U/L
SGPT (ALT) 91 < 40 U/L
Albumin 3.1 3.5 5.0 g/dL
Random Blood Sugar 130 < 140 mg/dL
Na 126 135 147 mmol/L
K 4.7 3.5 5.0 mmol/L
Cl 88 95 105 mmol/L
Resume
Patient came to the ward with abdominal
pain for 3 days, along with nausea but no
vomit.
He also felt general weakness. He hasnt gone
to any doctor to treat his complaint.
He was sent to internal medicine department
from ENT department because of increasing
SGOT and SGPT.
 Defecate and urinate within normal limit.
He said that he loss his voice 8 months ago
then he came to the doctor. He undergone CT
scan, bronchoscopy and biopsy. The result
was Larynx carcinoma.
2 months ago, he complained feeling out of
breath. He undergone tracheostomy and he
was assembled with a NGT by his
otolaryngologist.
 PE result : Anemic conjunctiva on both eyes,
thorax within normal limit, tenderness on
epigastric region, liver and spleen
enlargement (-), extremities within normal
limit.
Lab result : Hypochromic microcytic anemia,
leucocytosis, increasing of transaminase
enzyme, hypoalbuminemia, Hyponatremia
List of Problem

1. Larynx carcinoma
2. Dyspepsia Syndrome
3. Increasing of transaminase enzyme and
hypoalbuminemia
4. Hypochromic microcytic anemia
Discussion

1. Larynx carcinoma, based on:

HT : based on his anamnesis that undergone
ct scan, bronchoscopy and biopsy. The result
was larynx carcinoma.
Lab result : leucocytosis.
Diagnostic plan : -
Treatment plan : Chemoterapy, ENT consult.
2. Dyspepsia Syndrome, based on:
HT and PE : abdominal pain, nausea (+),
vomit (-), tenderness on epigastric region
Lab result : -
Treatment plan : Sukralfat 3x1 cth,
omeprazol 1x40 mg
3. Increasing transaminase enzyme and
hypoalbuminemia, based on:
HT and PE : abdominal pain, nausea (+),
history of increasing SGOT and SGPT,
defecate and urinate within normal limit,
icteric sclera (-/-), hepatomegaly (-),
yellowish skin (-)
Lab result : SGOT (100), SGPT (91), albumin
(3.1)
dd/ Hepatitis, Non-alcoholic fatty liver, ca
metastasis
 Diagnostic Plan : Total billirubin, direct and
indirect billirubin serum level, anti HAV, Liver
USG, IgM anti HAV, HBsAg
Treatment Plan : SNMC 1 amp (evaluate after
30 min), Hepamerz (L-ornithine L-aspartate)
1x1.
4. Hypochromic microcytic anemia, based on:
HT and PE : general weakness (+), anemic
conjunctiva (+/+)
Lab result : HB (10.8), MCV (74), MCH (26),
MCHC (34).
dd/ anemia e.c chronic disease, iron
deficienncy
Diagnostic plan : ADT, Iron serum, TIBC,
ferritin level
Treatment plan : -
Prognosis

Quo ad Vitam : Dubia ad Malam

Quo ad Sanationam : Dubia ad Malam
Quo ad Functionam : Dubia ad Malam
Thank You