POMR

TPL PPL IDX PDX PTX PMO

1. 1.P/60 yo/RHCU/private 1. Respiratory 1.1. • Recheck BGA • O2 8-9 lpm NRBM • Vital sign
payment failure type Pneumothorax • IVFD NaCl 0,9%  20 • Clinical
Anamnesa II (resolved) D spontan dpm features
• SOB intermitten since 3 sekunder • BGA
years worsening 1.2 COPD AE
afternoon type I
• Cough 3 months.
Worsening in a week
• greenish sputum
• decreased of appetite
and body weight (? Kgs)
since 1 month ago
• History of chest pain
since a week ago
Physical examination
• HR 122 bpm
• RR 32x/min
• BS: ↓/V
• Rh -/-
• Wh -/-
• Tax: 37,3
Laboratorium finding
• BGA :
7,14/74,2/146/25,6/-
Respiratoty
3,6/97,7%
• CXR Pulmo D : Collapse
of the lung with clear
Failure
zone 20%
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1.Y/51 yo/ER/JKN 1. 1.1 Lung TB • BGA • O2 9 l/m NRBM • Clinical
Anamnesis: Respiratory inactive serial/12 • IVFD NaCl 0,9% features
• SOB worsening 1 week failure type dd/aktif kx hours loading 500cc then • Vital sign
• Cough worsening 1 II SOPT , continue with 20 • BGA
week
Atalektasis dpm
• Fever 1 week
sinistra • Treat underlying
1.2 Pneumonia disease
P. Examination: CAP PS 131 RC • Consult to anesthesy
• GCS: 456 V + septic dept
• HR: 94bpm condition
• RR: 35x/mnt
• Ausc : V/V decrease, Rh
-/+, Wh -/-

Laboratorium:
• Leucocyte : 15.490
• Neutrophyl: 83,9%
• SGOT/SGPT: 1275/875
• UR/CR: 54,7/1,01
• BGA : pH 7,20, pCO2
79,4, pO2 67,3 with O2
NRBM 10 l/m
Respiratoty
Radiologi:
• CXR : fibroinfiltrate in
Failure
right area and opacities
in left area
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1.Mrs. P/52yo/BPJS 1. Pleural 1.1 Lung Tumor • Pleuroscopy • O2 4 lpm NC Vital sign,
History taking: effusion D dextra + biopsy • IVFD NS 20 dpm Clinical
• SOB 1 month Reccurent 1.2 • Repeated • Thoracentesis  features,
• Cough 2 months susp. MPE Mediastinum Pleural fluid 1100 cc Pleural
• Decrease of body tumor cytologi hemorhagic effusion
weight 1.3 volume
• Right chest pain 1 mo • Treat underlying
Mesothelioma disease
P. Examination:
• RR 27 x/mnt • Pleurodesis if
• VAS: 2 (mild) MPE (Malignant
• I: St: D>S, Dy: D<S Pleural Effusion)
• Palp: SF /N confirmed
• Perc: D/S
• BS /N, Rh -/-
• Pleural fluid:
hemorhagic
Laboratory finding:
• Leuco: 10.530
• Mono: 7,1
• BGA: moderate
hypoxemia Pleural Efusion
• PF analysis: exudate
(MN predominant)
• Cytology: class III
Radiology:
• CXR: D: radiopaque
homogen appearance
in middle & lower
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2.P/60 yo/RHCU/private 2. Pneumothorax 2.1 COPD AE type • CXR after • O2 8-9 lpm NRBM • Clinical
payment D spontan 2 insertion thorax • IVFD NaCl 0,9% 20 features
Anamnesa secunder 20% 2.2 Pneumonia catheter dpm • Vital sign
• SOB intermitten since 3 CAP • Consult to • Thorax drain • CXR
years worsening 2.3. susp Lung TB Rehabilitation insertion and
afternoon Medic (chest connect with
• Cough 3 months. fisiotheraphy) active suction -5
Worsening in a week cm H2O
• greenish sputum
• decreased of appetite
and body weight (? Kgs)
since 1 month ago
• History of chest pain
since a week ago
Physical examination
• HR 122 bpm
• RR 32x/min
• BS: ↓/V
• Rh -/-
• Wh -/-
• Tax: 37,3
Laboratorium finding
• Leucocyte :21.800
• Neutrophil : 85,7% Pneumothorax
• BGA :
7,14/74,2/146/25,6/-
3,6/97,7%
• CXR Pulmo D : Collaps of
the lung with clear zone
20%
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3. P/60 yo/RHCU/private 3 Acute lung 3. 1 Pneumonia • Sputum gram, • O2 8-9 lpm NRBM • Clinical
payment infection CAP PS 110 RC culture, • IVFD NaCl 0,9% 20 dpm features
Anamnesa IV + Septic sensitivity • Ceftriaxone 2x1 g IV • Vital sign
• SOB intermitten since 3 condition • Blood culture • Levofloxacyn 1x750 mg • Urine output
years worsening • Paracetamol 3x500 mg • Routine
afternoon PO hematology
• Cough 3 months. • N-Acetil Cystein 3x200 (Leu, Neu)
Worsening in a week mg PO • Check Lactat
with greenish sputum acid &
• Low grade fever & night proalcitonin
sweating since a week • CXR
ago evaluation
• decreased of appetite after
and body weight (? Kgs) antibiotic
since 1 month ago therapy
• History of chest pain
since a week ago
Physical examination
• HR 122 bpm
• RR 32x/min
• BS: ↓/V
• Rh -/-, Wh -/-
• Tax: 37,3
Laboratorium finding
• Leucocyte :21.800
Pneumonia
• Neutrophil : 85,7%
• BGA :
7,14/74,2/146/25,6/-
3,6/97,7%
- CXR: Pulmo D : Infiltrate
with air bronchogram &
fibrosis, cavitas (-) on
upper,
- Pulmo S: infiltrate on
upper
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2. Mrs. Suliatiningsih/52 yo 2. Acute lung 2.1. Pneumonia CAP • Blood culture • O2 15 lpm JR • Clinical features
History Taking infection PS 192 RC V + Septic • Sputum gram • IVFD NS 0,9% loading 500 cc • Vital sign
>decrease of consciousness gradually since Shock culture +DST then 20 dpm • Urine Out put
yesterday • Drip NE 8mg start 0,05mcg/KgBB • CXR evaluation
>Shortness of breath since 1 weeks ago. It • Inj. Ceftriaxone 2x1gr IV after antibiotic
has been getting worse since yesterday • Inf. Levofloxacin 1x750mg IV therapy
>Intermitten cough since 3 days ago • Per NGT: NAC 3x200mg • Lactate acid and
>Accompanied with whitish sputum which Procalcitonin
hard to expectorate monitoring
Physical Examination
GCS E3V4M5
Td 80/60 On NE
HR 128
RR 38
SpO2 87-88% on Jackson Reese
Temp 36,7
Ins D<S
Palp SF D/S -
Perc Dullness on the Left side
Aus BV and Rhonki on Right side
Laboratory Findings
DL 10.7/33.7%/10.500/321,000
DC 0.0/0.2/79.3/10.8/9.6
Limf Count 820
Ur/Cr 39/1.02
Ot/Pt 33/16
Bil T/D/I 0.48/0.31/0.17
Alb 2.9
SE 120/5.58/89
Gds 103

Pneumonia
Lactate Acid 5.5
BGA 7.14/75.2/85.3/25.7/-3.5/92.0
Port Score 192
Radiology – Thorax Photo
- D : Infiltrate forming air bronchogram +
on middle and lower area, fibrotic -,
cavity –, radiopaque app in lower area
- S : Covered by inhomogenous
radioopaque appeareance with
atelectasis component
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1.Mr.S/75yo/W.6/JKN 1. Lung 1.1. susp •Sputum •O2 2 liter per minute Vital sign,
• SOB 1 month Tumor carcinoma cytology NC Clinical
• Cough 7 month bronchogenik •USG Abdomen •Infusion NaCl 0.9% 18 features
• Decrease of body weight Sinistra T4NxM1b •CT Scan Thorax dpm Cek
• Disfonia(+) St. IV + contrast •Codein 3x10mg Cea/Nse
• Headache (+) susp.metastase •Head CT Scan •Paracetamol
• Chest pain (+) Liver ,susp.Meta •FOB 3x500mg
• Active smoker brain,laryng KS 50- •Transthoracal
P. Examination: 60 FNAB with USG
• BP 140/90 mmHg Complication: guiding
• HR 100 x/mnt - Disfonia
• Spo2: 99% 4lpm NC - Cancer pain
• RR 24 x/mnt
• Vs: 3/10
• Rh +/+, Wh -/-
• Abdomen: hepar palpable
• Leuco: 8.000
• Limfosit count: 648
• CXR: massa radioopaque
app Ø5-6cm
• BGA:
Hyperoxemia
Normal BGA
Lung Tumor
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2.Mrs.P/52yo/BPJS 2. Susp. 2.1. Susp. Lung • Sputum • O2 4 litre per Subjective
History taking: Thoracic Tumor D citology minute NC (chest
• SOB 1 month Malignancy T0NxM1a std IVA • USG abdomen • IVFD NaCl 0.9% 20 pain), Vital
• Cough 2 months with cancer • Repeated dpm sign,
• Right chest pain 1 pain (mild) 2.2. Susp. plerual fluid • Paracetamol Clinical
month Mesothelioma cytology 3x500mg PO features.ch
• Decrease of body • Fiber optic • Codein 3 x 10 mg eck CSE&
weight 2.3. Susp. bronchoscopy PO NSE
• Mass in others organ - Mediastinum • Pleuroscopy +
P. Examination: Tumor biopsy
• RR 27 x/mnt • CT Scan
• VAS score: 2 (mild) Thorax +
• I: St: D>S, Dy: D<S contrast
• Palp: SF /N • Trans-thoracal
• Perc: D/S, Aus: /V FNAB with
USG/CT
• P. effusion: guiding
haemorhagic
Laboratory finding:
• Leu: 10.530
• Mono: 7,1 %
• BGA: moderate
hypoxemia
• PF analysis: exudate
(MN predominant)
• PF cytology: class III
Radiology:
• CXR: D: radiopaque
homogen appearance in
Lung Tumor
middle & lower
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4 P/60 yo/RHCU/private 4.Chronic 4.1. COPD • Spirometry (if • O2 8-9 lpm NRBM • Vital sign
payment obstruc Acute patient in • Metilprednisolon • Clinical
Anamnesa tive Exacerbation stable 3x62,5 mg IV  GA features
• SOB intermitten since 3 disease Type 2 condition) USAH KEUALI ADA • Recheck
years worsening WHEEZING Leucocyte
afternoon • Nebulization
• Cough 3 months. Ipratropium
Worsening in a week bromide 0,5 mg,
• greenish sputum salbutamol sulfat
• Smooker 2,5 mg 4x/day
Physical examination • Nebulization
• HR 122 bpm budesonide 0,5 mg
• RR 32x/min 3x/day
• BS: ↓/V
• Rh -/-
• Wh -/-
• Tax: 37,3
Laboratorium finding
• Leucocyte :21.800
• Neutrophil : 85,7%
• BGA :
7,14/74,2/146/25,6/-
3,6/97,7%
COPD
- CXR: :Emphysematous
lung
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6.Mrs.P/ 52 yo/W24A/JKN 6. 6.1 Asthma •Spirometri •02 4 lpm NC Vital sign,
History taking : Obstructive bronchiale •Bronchodila •Salbutamol clinical
• Intermitten SOB since 2 lung intermitten tor test nebulization if features,
years (about 1x/month) disease in stable needed
• Respond to inhaler condition
bronchodilator 6.2 ACO
• Trigger: cold weather, dust,
fatigue
• History of asma (+)?
• Cough 3 days
• Low grade fever 5 days
P. Examination:
• BP :140/90
• HR 107x/mnt
• RR 27 x/mnt
• Ausc: Wh -/-
Laboratory
• Leuco: 10.530
• Eosinofil: 4,3
• Neutrofil: 74,80%
• Lymp count: 1095 ASTHMA
Radiologic
• CXR: D: radiopaque
homogen appearance in
medial & lower
• S: infiltrat perihilar
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5. P/60 yo/RHCU/private 5. Chronic lung 5.1 Susp Lung • Sputum • OAT 1st cathegory • Clinical
payment infection TB Genexpert if TB is confirmed features
Anamnesa • Sputum AFB S/M • Vital sign
• SOB intermitten since 3 • Sputum in media • Body
years worsening LJ weight
afternoon • CXR
• Cough 3 months.
Worsening in a week
• greenish sputum
• Low gread fever &
night sweatinf since a
week ago
• decreased of appetite
and body weight (?
Kgs) since 1 month ago
Physical examination
• HR 122 bpm
• RR 32x/min
• BS: ↓/V
• Rh -/-
• Wh -/-
• Tax: 37,3

Lung TB
Laboratorium finding
• Leucocyte :21.800
• Neutrophil : 85,7%
- CXR: Pulmo D :
Infiltrate, fibrosis,
multiple cavities
diameter 0.3-0.5 on
upper,
- Pulmo S: infiltrate on
upper
 TPL PPL IDX PDX PTX PMO
1.Mrs RI/54 1. AMS 1.1. Tend to • BGA serial/ • O2 NRBM 7-8 l/m • Clinical
yo/ER/Private Payment Respiratory 12 hours • IVFD NS 0,9% 20 bpm features
Anamnesis: failure type I • In Levofloxacin • Vital sign
DOC since 1 day 1.2. Hypoxic 1x750mg / day • BGA
• Cough since 3 week encephalopathy • Inj Ceftriaxone
• Whitish sputum 1.3 Septic 2x1gr / day
• SOB since 2 days encephalopathy • Treat underlying
• Fever since 3 days 1.4 CVA disease
• History HT (+) • Consult to
anastesiology dept
P. Examination: • Consult to neurology
• GCS: 334 dept.
• HR: 120 bpm
• RR: 28x/mnt
• Tax: 39,5oC
• Ausc : V/V, Rh -/-, Wh -/-
• Sofa Score : 5
Laboratorium:
• Leucocyte : 9.120
• Neutrophyl: 74,7%
• BGA : Alkalosis
respiratoric, Tend to
AMS
Resp Failure type 1

Radiologi:
• CXR : Infiltrat
parakardial dextra
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3. Mr.S/75 y.o/W.6/JKN 3. 3.1 low intake •Recheck •Diet HCHP + ekstrak Albumin
Decrease of appetite, hypoalbumin 3.2 chronic albumin level kutuk + ekstra white egg level
decrease of body weight emia disease
Alb : 3,09

4.Mr.S/75 y.o/W.6/JKN 4. Dyspepsia 4.1 Metastase Clinical

Abdominal discomfort syndrome Liver •Inj Lansoprazole 1x1 feature
Nausea (+) Vomiting (-) amp iv

5. Mr.S/75 y.o/W.6/JKN 5. 5.1 Ca Treat underlying Clinical

Chronic cough, decrease of Immunocom bronchogenik diseases feature
body weight promised
BMI : 17.71 state
Limfosit count: 648

Imunocompromised state
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3. M/28 yo/RHCU/JKN 3. Immunoco 3.1 HIV St IV • Treat underlying • Vital sign

Anamnesis: mpromised 3.2 Chronic disease • Clinical
• Stomatitis (+) state disease • Consult to Internal features
• Risk factor : multipartner Department
sex
• Decrease of appetite
• Decrease of body weight
P. Examination:
• BMI: 18,73 kg/m2
• Oral trush (+)
Laboratorium:
• Lymp. count : 108
• Alb: 1,6
• Determinant test: reactive
Imunocompromised state
Radiology: Azotemia
• CXR :
‐ TB Millier

4. M/28 yo/RHCU/JKN 4. Azotemia 4.1. Volume • IVFD NaCl 0,9% 20 • Vital sign
Anamnesis: prerenal dd depletion dpm • Clinical
• Nausea , vomiting (-) renal 4.2. Reactive • Consult to Internal feature
Department • RFT
Laboratorium:
• Ureum: 92,6
• Creatinin: 2,12
• GFR: 37,42
• BUN: 43,27
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6.P /63 yo/RHCU 6. Dyspepsia 6. Dyspepsia • Lansoprazole 1x30 Vital sign,

/private payment syndrome syndrome mg IV Clinical
• Decrease of features
appetite
• Pain like stubbing
sensation on
epigastric area
Dyspepsia
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5.Mr.N /59 5. Dyspepsia 5. 1 Increased -Endoscopy • Omeprazole 1x40 Vital sign,

yo/W.27/Private syndrome of mg IV Clinical
payment transaminase • Metoclopramid features
• Nausea (+) 5.2 PUD 3x1omg IV
• Vomiting (+)
• Decrease of appetite
(+)

Dispepsia
9. M/28 9. Oral 9.1 Immuno • Nystatin drop 3x1 cc PO • Clinical
yo/RHCU/JKN candidiasis compromised features
• White spot at state
tongue and oral
cavity
Oral Candidiasis
4.Y/51 yo/ER/JKN 4. Increase of 4.1 Reactive to • HbsAg, Anti • Treat underlying • Vital sign
Anamnesis: transaminase septic HCV disease • Clinical
• Fever 1 week 4.2 Viral hepatitis • USG • Consult to Internal features
Abdomen Department • LFT
P. Examination: • Curcuma 3 x 1 tab
• GCS: 456
• HR: 94bpm
• RR: 35x/mnt
• Abdomen : hepar palpable
with smooth contour,
consider hepatomegaly

Laboratorium:
• SGOT/SGPT: 1275/875
Inc Transaminase
• Bil Total/Diret/Indirect :
1,70/1,05/0,65 Hipo Natremi

5.Y/51 yo/ER/JKN 5. 5.1Volume • Treat underlying • Vital sign

Anamnesis: Hiponatremia depletion disease • Clinical
• General weakness 5.2 Low intake • IVFD NaCl 0,9% features
loading 500cc then • Serum
P. Examination: continue with 20 Electrolyte
• GCS: 456 dpm
• HR: 94bpm • Consult to Internal
• RR: 35x/mnt Departement

Laboratorium
Na/K/Cl : 126/5,62/92
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5. Mrs RI/54 yo/ER/private 5.Anemia HM 5.1 Fe • Blood • Consult to Internal • Complete

payment deficiency smear Department hematolo
• Hb : 9,30 g/dL 5.2 Chronic • SI, TIBC, gy post
• MCV : 68,0 fL disease Feritin transfusio
• MCH : 21,00 pg n
• MCHC : 31,0 g/d5

6. Mrs RI/54yo/ER/Private 6. DM 6.1 DM type II • FBS • Consult to Clinical

Payment • 2HPP BS Internal feature
• History of Diabetes • HbA1C Departement: FBS
mellitus(+) • Diamicron 2HHP BS
• Treated by Internist 1x30mg
using Diamicron and • Glucophage
Glucophage 1x500mg
• RBS : 154
7. Mrs RI/54yo/ER/Private 7. 7.1. • Recheck • HCHP diet, extra • Clinical
Payment Hypoalbuminemia Hypercatabolic albumine white egg features
• Decrease of appetite state • Albumine
• Albumine : 2,93 7.2 low intake

Anemia / DM /
Hipoalbumin
 TPL PPL IDX PDX PTX PMO

8. Mrs RI/54 y.o/ER/Private 8. Hypokalemia 8.1 dt Low • Consult to • SE

Payment Intake internal monito
Kalium = 2,92 departement : ring
KSR 1x600mg

9. Mrs RI/54yo/ER/Private 9. Trombositopenia 9.1 Septic •Procalsitoni • Consult to Clinical

Payment 9.2 Viral n Internal feature
• Trombosit 214.000  Infection • DL/ Day Departement:
131.000

Hipokalemi
Trombositopeni
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4. Mrs.P/52 yo/ER/JKN 4. 4.1 Liver • According to • Treat underlying • Vital sign
Anamnesis: Hyperbilirubi metastases primary disease • Clinical
• Fever 1 week nemia malignancy • Consult to internal features
• Decrease of appetite 4.2 department • Billirubin
• Nausea Obstructive • USG recheck
P. Examination: jaundice abdomen
• GCS: 456
• HR: 105 bpm 4.3
• RR: 27 x/mnt Reactive to
• Abdomen : hepar not infection
palpable, pain (-)
• Icteric +/+
Laboratorium:
• Bil T/D/I :
1,89/1,56/0,33
• OT/PT: 28/38
Radiology:
• CXR: D: radiopaque HYPERBILIRUBINEMIA
homogen appearance
in middle & lower area
• S: infiltrat perihilar
 TPL PPL IDX PDX PTX PMO
4.Mrs RI/54 yo/ER/Private 4. Heart F: HF stg B Fc II • Lipid profile •Consult to cardiology VS, clinical
Payment Failure A: RVH dept feature
Anamnesis: E: HHD • Interna Dept :
SOB since 2 days - Valsartan 1x80mg
History of HT(+)routine - Amlodipin 1x5mg
controlled:amlodipin
5mg,valsartan 80mg

P. Examination:
GCS: 334
HR: 126 bpm
RR: 28x/mnt
Tax: 39,5oC
Ictus palp ICS VI 2cm L
MCL S
Ausc : V/V, Rh -/-, Wh -/-
ECG : Sinus tachycardia
120 bpm
Laboratorium:
Leucocyte : 9.120
Neutrophyl: 74,7%
BGA : Alkalosis
respiratoric

Radiologi: Heart Failure

CXR : In filtrat parakardial
bilateral
apex embedded,
cardiomegaly,cardiac
waist (-)
 TPL PPL IDX PDX PTX PMO

7. M/28 yo/RHCU/JKN 7. 7.1 Anemia • SI, TIBC, • Consult to Internal • Vital sign
Anamnesis: Pansitopenia aplastic Blood Smear, Department • Clinical
• Decrease of appetite 7.2 MDS BMP features
• Decrease of body weight 7.3 • Routine
• Risk factor : multipartner Hematopoetic Haematol
sex inhibition dt HIV ogy

P. Examination:
• Eye: icteric +/+
Laboratorium:
• Hb: 9
• MCV: 74,3
• MCH: 24,1 PANSITOPENI
• PLT: 6000
• Leuko: 2.780
Radiologi:
• USG Abd: Splenomegali,
limphadenopathy paraaorta.

8. M/28 yo/RHCU/JKN 8. 8.1 SIADH • According to • Treat underlying • Vital sign

Anamnesis: Hyponatremia underlying disease • Clinical
• Decrease of appetite hypoosmolar disease • NS 0,9% 20 dpm features
euvolemic • Recheck
Laboratorium: SE
• Na: 129
• Osm:
 TPL PPL IDX PDX PTX PMO
1. M/22yo/ER/Private 1. 1.1 - Consult • O2 10 liter per Subjective,
Anamnesis Pneumomediastinu Pneumoni to BTKV minute non- Vital sign,
• SOB 1 month, m a (PCP) rebreathing mask Clinical
worsening 3 days, 1.2 Lung • IVFD NS 20 dpm features,
• History of forced TB far • Mediastinostomy CXR
coughing advanced • PO : Codein 3x10 Sign
• History of smoking lesion mg emphysema
(IB :240) • Consult to medical subcutis
rehabilitation for
P. Exam chest
• BP 120/85 HR 140 RR physiotherapy
40 • Wound care/day
• Neck swelling,
emphysema subcutis
• Thorax : St D=S ; Dn
D=S; SF N/N ;
S/S ; BS BV/BV, Rh
+/+
Lab :
• CXR: Continous
diaphragm sign,
double bronchial
Pneumomediastinum
sign, tubular artery
sign
• BGA: Hypoxemia,
Alcalosis metabolic
fully compensated
with ascidosis
respiratory,
Respiratory failure
type 1
 TPL PPL IDX PDX PTX PM

4.M/49yo/ER/JKN 4. Hemoptoe 4.1. Lung TB • FB • O2 2 lpm NC • Clinica

• Bloody streak last grade I 4.2. Pneumonia sputum • IVFD NaCl 0,9% 20 feature
morning CAP SM dpm • Vital si
• Chronic cough2 months 4.3 Susp Ca • Sputum • Tranexamic acid 3x500 • Blood
• Decrease of BW (+) Broncho D culture mg IV
• CXR : in LJ • Codein 3x10 mg PO
‐ Pulmo D : Radioopaque media • Lay down to the right
in upper area with • Sputum side
unspeculated margin, Gene • Educate how to cough
Infiltrat in middle area Xpert effectively

• Sputum
gram,
culture,
sensitivit
y test
• Blood
HEMAPTOE culture

• Cytology
sputum
• FOB
• USG
abdome
n
• CT scan
thorax +
contras
•FNAB
Transthor
acal
 TPL PPL IDX PDX PTX PMO
4.Mr.N /59 yo/W.27 /Private 4. 4.1. Primary •Lipid profile Consult Cardiology: Clinical
payment Hypert hypertension •Uric acid •Amlodipin 1x5mg features,
• History of uncontroled HT ension •Echocardiog Blood
• BP 160/80 mmHg stage II raphy preasure,
• HR 110 x/mnt
• RR 24 x/mnt
• EKG: LAE, LVH HT

7. Mrs. N.H /50 y.o/ER/JKN 7. 7.1 Diabetes - Fasting Blood •Consult to Internal Vital sign,
Anamnesa Endocrine melitus type II glucose Department  Clinical
• Nausea (+), vomiting (-) disorder - 2 hours post features,
• Decreased of appetite prandial blood Blood Sugar
• Decreased of body weight glucose
• History of DM on insulin in - HbA1c
previous hospital
Physical Examination :
• BMI: 23,68
Laboratory :
RBS: 286 mg/dL DM
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3. Mrs. N.H /50 y.o/ER/JKN 3.1. 3.1. cartagener •Sputum gram, •O2 10 lpm NRBM Vital sign,
Anamnesa bronchiectas synd culture, drug •IVFD NaCl 0.9% 1500 cc/ clinical
• Cough worsening since 4 days ago, whitish is sensitivity test  20 drip per minute features,
sputum 3.2 •Infusion Levofloxacin Leucocyte,
• SOB worsening 4 days dextrocardi 1x750 miligrams CXR
• Fever since a week ago intravenous
• History of chronic respiratory infection •NAC 3x200mg
Physical examination
• RR 23 x/mnt
• SpO2: 99% 10 lpm NRBM
• Ausc: V/V, Rh +/-,
Wh -/-
Laboratorium finding
• Leuco: 11160
• Neutrofil : 77,1
CXR:
• Pneumonia
• Bronchiectasis
• Lung moderate lesion
• dextrocardia

BRONKIEKTASIS