duty report 28 jan 2014

8/12/2019 DUty Report 28 Jan 2014

http://slidepdf.com/reader/full/duty-report-28-jan-2014 1/30

DUTY REPORT, DECEMBER

28TH OF JANUARY

2014

8/12/2019 DUty Report 28 Jan 2014


NURDIN, M ALE, 67 YO, MW 25

Cc : Breathless increased since 1 days ago.

Present illness History:

Breathless since increased since 1 days ago. Patient feel breathless

since 15 days ago. Breathless effect by activity. No influenced by

food and weather.

Patient feel better with high pillow

History wake at night cb breathless (+) Cough since 1 weeks ago, sputum (+), blood (-)

Patient known hypertension since 10 years ago,Uncontrolled.

No chest pain

Suddently blurr negative No headache

Vomite and nausea (-)

Decrease appetite since 1 week

Urnation and defication usual

8/12/2019 DUty Report 28 Jan 2014


Vital sign :

GA : Moderate Consciousness : CMC

Bp : 170/110 mmhg

Hr : 108 x/min

Rr : 36 x/min

Temp : 36,7 o C

Phisical examination : Eyes : no Conjungtiva anemic, no sclera icteric

Neck : Jvp 5-2 cmh2o , limph node unpapable

Lung :

Insp : simetris bilateralPalp : fremitus bilateral

Perk : sonor

Ausc : bronchovesicular, rales +/+, wheezing minimal

8/12/2019 DUty Report 28 Jan 2014


PHISICAL EXAMINATION

o Cor :

Insp : Ictus seen 1 finger lateral LMCS RIC VIPalp : Ictus palpable 1 finger lateral LMCS RIC VI

Perc : LSD, ictus 2 finger laterall lmcs RIC VI

Ausc : Murmur (-), reguler rhythm

abd :Insp : Enlargement of abd (-)

Palp : Lien unpalpable, liver palpable 1 finger bpx. Blund, flat. epigastric

pain (-)

Perc : Tympani and shifting dulness + minimal

Ausc : bowel sound (+) normal

Extremity : edema + minimal, FR +/+, PR -/-

8/12/2019 DUty Report 28 Jan 2014


LAB

Hb : 13.6 g/dL Ht : 15.6 %

Leucocyte : 14.600/ mm3

Trombocyte : 213.000/mm3

Gds : 132 Na/k/cl : 143/4.8/102

8/12/2019 DUty Report 28 Jan 2014


WD:o CHF fc 2, LVH RVH, VES infrequent cb HHD ( I. 130 )

o

BP (CAP) ( J. 180 )o HT stage 2 Cb essential ( I. 10 )

8/12/2019 DUty Report 28 Jan 2014


THERAPY

Rest/ DJ II/ o2 3 liters

Pump Inj, inj. Lasyx 1 x1 amp

Inj ceftriaxon 1 x 2gr IV

Ambroxol syr 3 x cth 2

Canderin 1 x 8 mg

PCT (when needed) Dulculax 1x tab 2

Fluid Balance

8/12/2019 DUty Report 28 Jan 2014


PLAN :

Exp chest x ray

Check Mg and Ca 2+ plasma

echocardiography

Sputum cultur

Oftamology consult

8/12/2019 DUty Report 28 Jan 2014


YULIANI, FEMALE, 44 YO, FW 11

Cc : fever since 4 days ago


Fever since 4 days ago, feve r continued quickly, high, no decreased

even with medication, chill and lot of sweats.

Fatigue since 6 days ago.

Vomite since 4 days ago, frcuency aprox 10 times a day with ¼-1/2

glass consist what she eats. no blood. No cought no breathless, history got OAT negative.

Defecate and urinary fluent.

History of thirsty, hungry and urinary at night since 3 months ago.

History of diabetic denied.

History of decreased weight on 2 years, but patient doesnt know how

many kg she loss.

History hypertension, hearth disease,kidney disease

8/12/2019 DUty Report 28 Jan 2014


Vital sign :


Bp : 110/70 mmhg

Hr : 120 x/min

Rr : 24 x/min

Temp : 38,8 o C

Phisical examination : Eyes : Conjungtiva anemic no , no sclera icteric

Neck : Jvp 5-2 cmh2o , limph node unpapable

Lung :


Perk : sonor

Ausc : vesicular, rales -/-wheezing -/-

8/12/2019 DUty Report 28 Jan 2014



o Cor :

Insp : Ictus unseenPalp : Ictus palpable 1 finger medial LMCS RIC V

Perc : LSD, ictus 1 finger medial lmcs RIC V


abd :Insp : Enlargement of abd (-)

Palp : Liver and Lien unpalpable, epigastric pain (-)

Perc : Tympani


Extremity : edema -/-, FR +/+, PR -/-

8/12/2019 DUty Report 28 Jan 2014


LAB

Hb : 12.6 g/dL pH : 7,42 Ht : 39 % pCO2 : 29

Leucocyte : 33.200/ mm3 pO2 : 72

Trombocyte : 117.000/mm3 HCO3- : 18,8

GDR : 395 Beecf : -5,7Ur/cr : 33/11 SO2 : 95%

Protein urine (+)

Keton urine (+)

8/12/2019 DUty Report 28 Jan 2014


8/12/2019 DUty Report 28 Jan 2014


WD:

o Septic cb uroseptic (N.30)

o

DM type 2 new normoweight (E.11)o Trombositophenia Cb Sugestif DIC (D.65)

8/12/2019 DUty Report 28 Jan 2014


THERAPY

Rest/ soft diet dd 1700kkal.

IVFD Nacl 0.9% 6 hours/kolf

Ceftriaxon inj. 1 x 2 gr (iv)

Ciprofloxacin inf 2 x 200 mg

Methylprednisolone inj 2 x 20 mg.

PCT 3 x 500 mg Insulin drip 50 unit with 50 cc Nacl 0.9% (drip critical ill)

Fluid Balance

8/12/2019 DUty Report 28 Jan 2014


PLAN :

Blood, urin, feces routin.

Blood cultur

Urin cultur

GDP/GD2PP

Oftamologist consult Nutritions consult

ECG

Exp chest x-ray

Urin keton Blood gass analys

8/12/2019 DUty Report 28 Jan 2014


DIAH INTAN SARI, FEMALE, 36 YO

Cc : Icteric since 10 days ago


Icteric since ten days ago

Diarrhea since 2 days ago, frequent > 3 x/days, muccous, no blood,

stinking aroma

Post partus 3 hours ago

Vomite since one day, every got eat. Frecuency 3 times consist whatshe eats.

No Black vomite. No blood

Urinary dark tea since ten days ago.

Defecate like pale doesnt known by patient.

Itchy on all bodies since 1 week ago.

No fever

Oedem on foots since 1 day ago

Urination and defication usual

8/12/2019 DUty Report 28 Jan 2014


Vital sign :


Bp : 110/80 mmhg

Hr : 78 x/min

Rr : 21 x/min

Temp : 37,3 o C


Neck : Jvp 5-2 cmh2o ,

Lung :


Perk : sonor

Ausc : vesicular, rales -/- , wheezing -/-

8/12/2019 DUty Report 28 Jan 2014



o Cor :




abd :

Insp : Enlargement of abd (-)


Perc : Tympani


Extremity : edema +/+, FR +/+, PR -/-

8/12/2019 DUty Report 28 Jan 2014


LAB

Hb : 11,3g/dL

Ht : 33%

Leucocyte : 15.800 / mm3


Aptt : 130,3 secPt : 37,7 sec

SGOT/SGPT : 249 / 132 u/L

Bil I : 3,4 mg/dL

Bil II : 21 mg/dL

D-dimer : 1,0

LDH : 856 u/L

Na : 115 K : 4,4 Ca : 94

8/12/2019 DUty Report 28 Jan 2014


WD:

o Extra hepatal choleistatic cb coledocolithiasis ( K.80.5)

o

P1a0h0 post maturity spontan with IUFD (O.900)o Suggestif DIC (D.65)

o Hyponatremia cb low intake (E.871)

8/12/2019 DUty Report 28 Jan 2014


THERAPY

Rest/ Liver diet II/ 02 3/liters

IVFD aminofusin hepar :triofusin 1 : 2 = 8 hours/kolf Correction NaCl 3 % 12 hours/kolf (2 kolf)

Ceftriaxon inj. 1 x 2 gr (iv)

Sistenol 3 x 500 mg

Curcuma 3 x 1 tab Vit K 3 x 1 amp (iv)

8/12/2019 DUty Report 28 Jan 2014


PLAN :

APTT/PT

D-dimer

Blood routin

Abdominal usg

Abd ct-scan

Faal hepar

Hepatitis marker

Profil lipid

8/12/2019 DUty Report 28 Jan 2014


INDRA DIPA, MALE, 46 YO,

Cc : Vomite since 1 day ago


Vomite since 1 day ago, frequent > 10 x/day, volume 1 glass/vomite,

content what he eats, blood (-)

Epigastric pain since 2 days ago, pain is not radiating, pain increase

when charging foods

Patient has known pairs of ring in heart since 3 years ago and drinkaspirin and plavix routin for 3 years. Stop therapy since 3 months

ago

Chest pain no

Fever (-)

Cough (-)

Patient has known HT since 3 years, controlled Sp. JP MD get

therapy concorde

Breathlessness (-), Swollen ol both legs (-)

Urination usual and defication usual

8/12/2019 DUty Report 28 Jan 2014


Vital sign :


Bp : 120/80 mmhg

Hr : 76 x/min Rr : 26 x/min

Temp : 36,5 o C


Neck : Jvp 5-2 cmh2o ,

Lung :


Perk : sonor

Ausc : vesicular, rales -/- , wheezing -/-

8/12/2019 DUty Report 28 Jan 2014



o Cor :




abd :

Insp : Enlargement of abd (-)


Perc : Tympani


Extremity : edema +/+, FR +/+, PR -/-

8/12/2019 DUty Report 28 Jan 2014


LAB

Hb : 14,6 g/dL

Ht : 43 %

Leucocyte : 11.600 / mm3


CKMB : 12 Troponin T : (-)

Na : 107 K : 2,4

Ur/cr : 10/1 mg/dL

8/12/2019 DUty Report 28 Jan 2014


WD:

Hiponatremia at Hipokalemia cb vomite cb gastrophty (

E.871)

Coronary arterial disease post PTCA (T.822)

8/12/2019 DUty Report 28 Jan 2014


THERAPY

Rest/ soft diet gastric diet II/ low salt II

Correction NaCl 3 % 12 hours/kolf (3 kolf) Correction KCl 35 meq in 200 cc NaCl 0,9% for 4 hours

Lansoprazol 1 x 30 mg

Sucralfat syr. 3 cth 1

Simvastatin 1x20mg Clopidogrel 1x75mg

Domperidon 3x10mg

Concor 1x2,5mg

Ramipril 1x2,5mg

Fluid balance

8/12/2019 DUty Report 28 Jan 2014


PLAN :

Routine BUF

Electrolite post correction

Ureum - creatinine

Gastroscopy

duty report 28 jan 2014

Documents