Duty report

December 5th, 2017

Ishaq 47 yo, MW 20
decrease of conscioussness since 1 days ago. Felt slowly
and looks sleepy.
Fever denial.
Cough since 1 week ago. Sputum (+)
Breathlesness (-)
Nausea and vomit (-)
fatique since 1 weeks ago.
Decrease of body weight since 2 weeks ago.
Decrease of apettite since 1 months ago
Patient had been get drug TB 6 months ago and
otherwise healed
Patient has been from prisoner
06/12/2017
 History DM and HT and stroke (-)

06/12/2017
Physical Examination
level of consciousness : somnolent

BP : 100 / 70 mmHg

HR : 88 x/minute

RR : 23 x/minute

T: 37,1oC
 Eye
Conjunctiva are anemic -/-
Sclera icteric -/-

Neck
JVP 5 - 2cmH20

Lung:
Inspection: simetric left = right
Palpation: fremitus difficult to assess
Percussion: sonor
Auscultation: bronchovesicular, Rh+/+, Wh -/-

Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger medial LMCS RIC V
Percussion:
Left border: 1 finger medial LMCS RIC V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: Pure rhythm, murmur(-)
 Abdomen:
Inspection: Enlargement (-)
Palpation: hepar and spleen unpalpable
Percussion: tympani
Auscultation: bowel sound (+) normal

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory
Examination Result
Hb 13, 7 g/dl
Leukosit 19690/ mm3
Trombosit 35300/ mm3
ht 40
Ur / Cr 32/0.9
GDS 83
Na / K / 124/2,4 /
Ph 7,64
Pco2 26
Po2 67
Hco3- 28
Beecf 7,1
so2 96

06/12/2017
Working Diagnose
Decrease of consciousness cb hypoxemia
Bronchopneumonia dupleks (CAP)
Relapse lung TB
Hyponatremia et hypokalemia
malnutrision
Therapy
rest / liquid diet 6x 50 cc / 02 2 l/i
IVFD nacl 0,9 % 8 hr
Ceftriaxone 1x2 gr
Paracetamol 3x 200 mg
Nebu flumucyl/ 8 hr
Correction KCL 25 meq in 200 cc nacl 0,9% in 4 hr
Fluid balance