Ward Room

Duty Report
Coass on duty : Aldwin and Murdono
General practitioner on duty : Cecep M.D

Patients Recapitulation
Tn. I Fever of unknown origin
Tn. F Low intake + SIDA on ARV
Ny. M CKD Stage V on HD pro CAPD
Tn. S CKD Stage V on HD repair tunnel
Tn. S CKD Stage V + SIDA Pro CAPD

Patients Identify
Name : I
Gender : Male
Age
: 37 years old
Occupation: PNS
Address : Kemayoran
Religion : Islam
Married: Married

Basic Information - Anamnesis

Chief Complain:
Fever since 2 weeks before hospital admission

Present History
The patient complain fever since 2 weeks before hospital
admission. The fever onset raise in the afternoon and night,
and down in the morning and evening. Fever never down until
normal. He feel fever continously. He use drug like
paracetamol and the fever down, but raise again.
He complain cough with phlegm since 1 year. The phlegm is
white and many. He use komik OBH drug to decrease the
cough but its useless. He feel malaise, nause, and muscle
pain. The defecation and urination with normal limit

 Present History
He deny feel disfagia, odinofagia, blood cough, breathless,
yellow, weight loss, vomiting, no pain when urinating, no
blood urin, no pain on waist, no diarrehea, no petechie, no
mucosal bleeding
He deny travel to endemic illness, get trauma, get injury, no
have pet at home, never change sex partner, never use drugs
very long time,

 History of past Illness

-

History of family illness

Hipertensi (-)
DM (-)
Coronary pain (-)
Hepatitis (-)

 History of medicine :
Paracetamol
OBH

Habit and lifestyle:

Smoking 1 warp for 3 days
Alkoholism (-)

Physical Examination
General stase : looked ill being
Awareness : E4M6V5
Vital sign:

BP : 120/80 mmHg
P: 100x/min
R: 22x/min
T: 37

Head to toe
Head : Normocephal
Eyes : anemic conjungtiva -/-, icteric -/ Nose : Secret -, nostril breath
Ear : tragus pain -, secret
Mouth : redness perifer tounge -, temor -, dry lips
Neck : KGB (+) 1 cm, JVP H-2
Thorax

 Lung ;

I : Simetris, retraction
P: taktil fremitus dextra = sinistra
P: Sonor
A: Bronkhovesikuler (+), wet
rohkhi +

Cor :

I : Ic unseen
P : Ic palpable
P: Normal, dim
A: S1>S2, murmur -, gallop -

Abdomen :

I : convex
A: intestine sound normal
P: tenderness
P: timpani

Extremitas

Edema : Sianotic : -

Lab hematologi
HB

11,4

13-18 g/dL

HT

33

40-52%

Eritrosit

3,8

4,3 6,0 juta uL

Leukosit

6640

4800 10800 uL

Trombosit

233000

150000-400000 /uL

MCV

30

80-96

MCH

30

27-32

MCHC

35

32-36

Lab chemical clinic

Ureum

21

20-50 mg/dL

Kreatinin

1.0

0,5 1,5 mg/dL

GDS

135

< 140 mg/dL

Na

135

135 147 mmmol/L

Kalium

3.0

3,5 5,0 mmol/L

Klorida

107

95-105 mmol/L

Urinalisis
Warna

kuning

kuning

Kejernihan

Agak keruh

Agak keruh

PH

6.0

4.6 8.0

Berat jenis

1030

1010 - 1030

Protein

Negatif

negatif

Glukosa

Negatif

Negatif

Bilirubin

Negatif

Negatif

Nitrit

Negatif

Negatif

Keton

Negativ

Negatif

Urobilinogen

Negativ

Negatif positif 1

Eritrosit

1-0-1

< 2/LBP

Leukosit

7-6-6

< 5.LBP

Silindris

Negatif

Negatif

Resume
Patient, man, 37 years old complain fever since 2 weeks
before hospital admission. The fever onset raise in the
afternoon and night, and down in the morning and evening.
Fever never down until normal. He feel fever continously. He
use drug like paracetamol and the fever down, but raise again.
He complain cough with phlegm since 1 year. The phlegm is
white and many. He use komik OBH drug to decrease the
cough but its useless. He feel malaise, nause, and muscle
pain. The defecation and urination with normal limit
Fever (+), anemia (+)

Planning
Drip Levofloxasin 750 mg
IVFD RL 500
PCT 3x500 mg tab

DD:

TBC
Tifoid Fever : Widal, tubex

Problem list
1. Fever of unknown origin
2. Anemia normositik normokrom

Disscussion
Fever of unknown origin
Anamnesa: intermitten fever for 14 days, productive cough (+),
malaise (+)
Physical examination: BP 120/80, P 100x, B 22x, T 37 C
Laboratory: leukosit within normal range
Planning diagnostik:
1. X-foto thorax
2. Sputum BTA
3. Diff count

Disscussion
Anemia normositik normokrom
Laboratory: Hb, Ht, Eritro, MCV; MCH; MCHC within
normal range
Planning diagnostik:
Serum iron
TIBC
Reticulosit