DUTY REPORT

Sunday, 12th July 2015

Dr. Rina

PHYSICIAN INCHARGE
IA : dr Rina, dr. Regy,
IB : dr. Somarnam
II CVCU : dr. Sasmithae
II HCU : dr. Ramadhan
II ER : dr. Hesti, dr. Zen
Chief : dr. Herwindo
Consultant : dr. Shinta Oktya Wardani, Sp.PD

Summary of Data base

Mrs. Kunti Badi’ah / 59 yo/ Ward.28

HISTORY TAKING : Autoanamnesa

CHIEF COMPLAINT : Nose bleeding

HISTORY OF PRESENT ILLNESS :

Patient suffered from nose bleeding since 1 day before admission, the bleeding continuously
especially at right nose. Sometimes accompanied bleeding from the left side nose.

This condition also accompanied with bleeding from her mouth, it was clotted blood with dark
colour, more than 10 times a day, the volume about 1-2 spoonfull.

Patient was diagnosed Multiple myeloma since 1 year ago, and She had performed chemotherapy
for 13 times. The chemotherapy had given are Melphalan 2x2 tab and Prednison 3x4 tab a day for 5
days every month

She also complaint about pain at her back since 1 year ago, the pain didn’t subsided though she
consumed MST to relieve the pain.

Past Medical history :

More than 10 times She had transfusion of PRC at RSSA due to Anemia.

She ever had epistaxis before, but she felt it the worst.

Family history : none of her family has the same symptom like her

Social History : She is a widow, as a housewife, has 3 children.

1
Physical Examination

GCS 456 General Appearance : look moderately ill

BP 130/80mmHg. PR : 84 bpm RR 28 tpm Tax 360 C
tachypneu
Looked underweight
Head Normocephal, anemic conjunctival (+), icteric scleral (-), epistaxis at
right nares
Neck JVP = R +3 cm H2Oat 300
No enlargement of thyroid gland
Thorax Cor Ictus invisible, palpable at ICS V, 1 cm lateral MCL sinistra
RHM ~ sternal dextra LHR ~ ictus cordis
S1 – S2 reguler, murmur (-)
Lung symmetric S=S v v Rh - - Wh - -
Stem fremitus S =S v v - - - -
D=S
S =S v v - - - -
Abdomen Flat, soefl, bowel sound normal, liver span =8 cm, Traube’s space
=tymphanic, shifting dullness (-)
Extremities dry skin (-), warm acral (+)

Laboratory Finding

Normal
Laboratory Result Unit
Value

Hb 9.80 11.4-17.7 g/dL

Leucocyte 2.88 4.700-11.300 /µL

Hematocrit 29.60 38-42 %

Thrombocyte 22.000 142.000- /µL

420.000

MCV 82.20 80-93 fL

MCH 27.20 27-31 pg

MCHC 33.10 32-36 g/dL

Differential count 0.7/0.3/44.2/34.7/20.1 0-4/0-1/51- %

67/25-33/2-
5

2
 SGOT 67 0-32 U/L

SGPT 81 0-32 U/L

RBS 89 <200 mg/dL

Ureum 30.80 16,6-48,5 mg/dL

Creatinine 0.60 <1,2 mg/dL

Sodium (Na+) 133 136-145 mmol/L

Pottasium (K+) 4.08 3,5-5,0 mmol/L

Chloride 111 98-106 mmol/L

PPT 11.10 9.4-11.3 sec

INR 1.06 0.8-1.30

APTT 23.10 24.6-30.6 sec

ECG:

 Sinus rhythm, Heart rate 80 bpm

 Frontal Axis : Normal
 Horizontal Axis : Normal
 PR interval : 0,16”
 QRS complex : 0,08”
 QT interval : 0,36”
Conclusion :Sinus trhythm with HR 80 bpm

CUE&CLUE PL IDx PDx PTx PMo

Female/59yo/w28 1. Epistaxis 1.1 Plexus Rehydration IVFD NaCl 0.9% S, VS,
Ax : Kiesselbach’s 20 tpm bleeding,
Diagnosed MM rupture Transfusion of TC 4 packs signs and
since 1 year ago 1.2 until trombosit > 20.000/μl or symptoms of
Had Hypertension thrombocytopenia bleeding stop dehydration
since 20 years ago Anterior tampon
BP ER : 170/80 Inj. Tranexamic acid 1 amp iv PEdu :
mmHg Underlying
at ward : disease,
BP : 130/80 management,
mmHg prognosa
HR : 84 tpm

3
RR : 28 tpm
Tax : 36°C

Female/59yo/w28 2. Hypertension 2.1 Primary USG Doppler Diet low salt < 2 gr/day BP
BP ER : 170/80 urgency (resolved) 2.2 Secondary renal artery Valsartan 1x160mg
mmHg 2.2.1 Renovascular PEdu :
at ward : 2.2.2 renal Funduscopy Underlying
BP : 130/80 parenchymal disease,
mmHg management,
HR : 84 tpm prognosa
RR : 28 tpm
Tax : 36°C
Female/59yo/w28 3. Multiple Melphalan 2x2 tab/day PEdu :
Ax : myeloma on Prednison 3x4 tab/day Underlying
Diagnosed MM treatment For 5 days every month disease,
since 1 year ago management,
Had performed prognosa
oral
chemotherapy 13
times
Female/59yo/w28 4. Pancytopenia 4.1 blood loss Treat underlying diseae S, VS
CKD stg 5 newly 4.2 Chronic Underlying
diagnosed disease disease,
Lab : 4.3 Multiple management,
Hb : 9.8 g/dl Myeloma prognosa
Hmt : 29.60%
MCV : 82.20 fl
MCH : 27.20 pg

Female/59yo/w28 5. Cancer pain dt MST 3x10mg PEdu :

Ax : pain at her Multiple Myeloma Underlying
back disease,
PE : VAS 8/10 management,
prognosa