Duty report

November 30 , 2016
Markius , male, 57 yo, HCU 15

Chief complain
breathlessness increase since
1 days ago
Present illness history
Breathlessness increase since 1 day ago,
actually felt since 5 days ago. Influenced
by activity, not influenced by food and
weather.
Swollen both of the leg since 1 week ago
Cough since 5 days ago, sputum (+)
Fever since 5 days ago, intermittent
History of hypertension since 5 years ago
Hystory of gout since 10 years ago,
tenderrness (-)
Physical Examination

Consciousness level: Soporous

BP : 150/90 mmHg

HR : 110x/minute

RR : 38x/minute

T: 37,4 C
 Skin: Eye
Conjunctiva anemic +/+
Sclera icteric -/-

Neck
JVP 5-2 cmH20

Thorax: spider naevi (-)

Lung:
Inspection: simetris dextra = sinistra,
Palpation: fremitus dextra = sinistra
Percussion : sonor
Auscultation: bronchovesicular, rh+/+, wh-/-
Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger lateral LMCS ICS VI
Percussion:
Left border: 1 finger lateral LMCS ICS VI
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: pure rhythm, murmur (-)
Abdomen:
Inspection: enlargement (-),
Palpation: hepar and spleen (-)
Percussion: tympani,
Auscultation: bowel sound (+) normal

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema +/+
Laboratory
Hb 7,8 gr/dl
Ht 23
WBC 32700/mm3
Platelet 226.000/mm3
RBG 110
ureum 377
creatinin 10,5
Na/K 134/3.8
PT/APTT 16,9/49,8
Ph 7.18
Pco2 14
Po2 65
Hco3- 5.2
Beecf -23,2
so2 86 %
Working Diagnose
Acute lung oedem with
respiratory failure type 1
Sepsis cb bronchopneumonia
(CAP)
CKD stage V cb nefrosclerosis
hypertension with acidosis
metabolic
Therapy
rest/ low protein 48 gr low salt II/ NRM 02 10 L/i
IVFD Easprimer 24 hour/kolf
Drip lasix 2,5 cc /hours
Ceftriaxone 1x 2gr
Levofloxacin 1x 500 mg 1x 250 mg
Nebu flumucyl/ 8 hr
Paracetamol 3 x 500 mg
Folic acid 1x 5 mg
Amlodipin 1x 5 mg
Candesartan 1x 8 mg
Fluid balance