Duty Report

August 4th , 2016

 Rosni , 68yo, fw 01
• CC:
• Breatlessness increase since 1 day ago

• Present Illness History:

• Breatlessness increase since 1 day ago, has felt since 1
week ago. Not affected by activity, food and weather.
• Fever 3 days ago. Fever high.
• Cough since 5 days ago. Sputum (+).
• Swelling of abdomen since 2 weeks ago. Pain (-)
• Patient looked delirium since 3 days ago
• Nausea and vomite since 3 days ago.
• Initially patient hospitalized in surgery warm since 2 weeks ago and
than reffered to internal medicine warm.
• Micturation and defecation normal
• History of illness:
• History of DM (+)
• History of HT (-)
 Physical Examination
• Consciousness level: CMC

• BP : 130/90 mmHg

• HR : 120x/minute

• RR : 30x/minute

• T : 37,5 C
• Skin: skin turgor is normal
• Eye
• Conjunctiva are anemic +/+
• Sclera are icteric -/-

• Neck: JVP 5-2 cmH20

• Lung:
• Inspection: simetric at statis and dinamic
• Palpation: left = right fremitus
• Percussion: sonor
• Auscultation: Bronchovesicular, rales +/+, wheezing -/-

• Cor:
• Inspection: ictus not seen
• Palpation: ictus is palpated at 1 finger medial LMCS RIC V
• Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: RIC II
• Auscultation: pure rhythm, murmur (-)
• Abdomen:
• Inspection: enlargement (-)
• Palpation: hepar and lien is not palpable
• Percussion: tympani
• Auscultation: bowel sound (+) normal

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

Hb 8,0 gr/dl PH 7,22

Ht 22 % PCO2 54
WBC 22.040/mm3 PO2 132
Platelet 305.000/mm3 HCO3- 7,0
Ur/Cr 521/15,3 BEecf -20,7
Na/K/Ca 132/4,5/5,9 SO2 80%
RBG 250 SGOT/SGPT 37/11
Alb/Glb 3,0/2,8
 Working Diagnose
• Septic ec Bronchopneumonia with Respiratory failure I
• Acute on CKD cb Diabetic Kidney Disease with
Metabolic acidosis and Uremic Enchefalopathy
• Hypocalsemia cb CKD
• Type 2 DM uncontrolled Normoweight
• Moderete anemia cb chronic disease
• Intraabdominal tumor
 Therapy
• Rest/DD 1700 kkal liquid diet 6 x 200cc/NRM 10L/1’
• IVFD NacL 0,9% 6 hours/colf
• Inj. Ceftriaxon 1 x 2gr (iv)
• Inf. Ciprofloxacin 2 x 200mg  1 x 200mg
• N – acetylsistein 3 x 200mg (po)
• Meylon correction 250 mEq in 250cc Nacl 0,9%
• Drip Ca Gluconas 3 amp in 100cc NacL 0,9% finished 1 hour
• Folic acid 1 x 5mg (po)
• Inj. Novorapid 3 x 8 IU
• Bicnat tab 3 x 500mg (po)