Duty Report

August 7th, 2020

 Yusmimar 68 y.o, female, FW 12
• Cc:
 Decreased consciousness since 4 days ago.

• Present Illness History

 Decreased consciousness since 4 days ago. happened slowly, initially the patient was a lot sleepy until now it is
difficult to wake up
 Breathlessness  Increased since 4 days ago. , was affected by activity, was not affected byweather and food. 
 History of leg swelling (+)
 Fever since 3 days ago continuously with sweating (-) shivering (-)
 Cough since 3 days ago with white phlegm (+) bloody(-)
 Decrease of appetite since 3 days ago
 Black stool since 2 days ago. Frequency3 times/day
 Hystory of epigastric pain denial
 History consumtion of NSAID (-)
 History of bleeding: Gum bleeding (-) Skin bleeding/ bluish on the skin (-), nosebleed(-) black vomit before (-)
 Micturition was was normal 
 Patient had been known since 8 years ago. Uncontrolled. After stroke Patient only activity in bed.
• History of HT since 1 year ago uncontrolled
• History of DM since 8 year ago controlled
• History of Stroke since 8 year ago
 Physical Examination
• Consciousness level: Sopor

• BP : 107/72  mmHg

• HR : 88 x/min

• RR :  26x/minute

• T:  38,3 oC
• Skin : ptechiae (-)
• Eye
• Conjunctiva anemic  (-)
• Sclera  icteric (-)

• Neck
• JVP 5+3 cmH20

Lymph Node: unpapble

• Lung: 
• Inspection:  symetric left=right
• Palpation: fremitus left=right
• Percussion:  sonor
• Auscultation: bronchovesicular, rales +/+ innbasal both of lung
wheezing -/-
 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: reguler, murmur (-)
• Abdomen:
• Inspection: enlargement (-)
• Palpation: Hepar and lien unpalpable
• Percussion: tympani,
• Auscultation: bowel sound (+) normal
• Flank : knocking and pressure pain at CVA -/-
• Extremities:
• Edema+/+
• Physiologic Reflex +/+
• Pathologic Reflex -/-
 Laboratory
Hb 15 g/dl Ur 79 mg/dl pH 7,38
Leukocyte 9690/mm3 Cr 1,1 mg/dl HCO3 19,7

Platelet 122.000/ Na 137 mmol/L PC02 33

mm3
HT 45 K 3,4 mmol/L P02 176

Diff 0/0/81/11/8 Cl 106 mmol/L S02 100

Count
PT 11,7 s Ca 8,1 mg/dl BE -5,6

APTT 25,9 s Albumin 3,1 g/dl SGOT 69 u/L

INR 1,06 Globulin 2,9 g/dl SGPT 22 U/L

D-Dimer 1115
ng/mL
Ro Thorax
ECG
 Working Diagnose
•Decreased consciousness ec Septic Associated Encephalopathy
•Syok sepsis ec Community Acquaired Pneumonia
•Community acquired pneumonia with bilateral pleural effision Sinitra
•Hematemesis ec stress ulcer
•High Risk VTE
•AKI Stage I ec pre renal ecc sepsis
•CHF FC II LVH RVH Sinus Rhythm ec Atherosclerosis Heart Disease
•DM Type II Controlled Normoweight
•Old Stroke with immobilitation
 Differential Diagnose
•Decreased consciousness ec Acute
confusional state
•Hematemesis ec peptic ulcer
•AKI Stage I ec pre renal ec dehidration
 Therapy
• Rest/ Liquid diet diabetic diet 1700 kcal low salt II Diet Low Protein 48 gr/ o2 5 L
• IVFD Nacl 0,9 % 8 hours/kolf
• Inj ceftriaxone 2x1 gr iv
• Inj levofloxacin 1x750 g iv
• Drip lansoprazole 30 mg in 100 CC NaCl 0,9% 4 times aday in 1 hours
• Inj transamin 3x500 mg iv
• Inj vit k 3x10 mg iv
• N-Acethylsistein 3x200 mg po
• Atrovastatin 1x20 mg po
• Bisoprolol 1x2,5 mg po
• Ramipril 1x1,25 mg po
• Fluid balance
Plan

• Check Hb serial if massive bleeding

• Check GDP,GD2PP,HbA1c
• Sputum culture
• Echocardography
 1. Pasien perempuan, Ny Y, 68
Diagnosis thyang telah dilakukan
Hasil pemeriksaan

•Penurunan kesadaran ec Septic Hb 6,2 g/dl Ur 11 mg/dl Albumin 3,3 g/dl

Associated Encephalopathy
Leukocyt 1.910/mm3 Cr 0,5 mg/dl Globulin 2,1 g/dl
•Syok sepsis ec Community e
Acquaired Pneumonia
•Community acquired Platelet 9.000/mm3 Na 138 mmol/L SGOT 65 u/L
pneumonia dengan bilateral
efusi pleura Sinitra HT 18 K 3,6 mmol/L SGPT 86 U/L
•Hematemesis ec stress ulcer Diff 0/0/1/56/40 Cl 109 mmol/L PT 10 s
•High Risk VTE Count
•AKI Stage I ec pre renal ec
sepsis MCV 81 Ca 8,7 mg/dl APTT 28,6 s
•CHF FC II LVH RVH Sinus
Rhythm ec Atherosclerosis MCH 29 Reticuloc 2,09 INR 0,89
Heart Disease yte
•DM Type II Controlled
MCHC 35
Normoweight
•Old Stroke dengan
immobilitation
Terapi yang telah Terapi saat ini Tindakan yang akan
diberikan dilakukan
•Drip lansoprazole 30 mg •Rest/ MC DD1700 kcal Check Hb serial Check
dalam 100 CC NaCl RGII gr/ o2 5 L GDP,GD2PP,HbA1c
0,9% 4 x sehari dalam 1 •IVFD Nacl 0,9 % 8 Sputum culture
jam hours/kolf Echocardography
•Inj transamin 3x500 mg •Inj ceftriaxone 2x1 gr iv
iv •Inj levofloxacin 1x750 g
•Inj vit k 3x10 mg iv iv
•Drip lansoprazole 30 mg
dalam 100 CC NaCl
0,9% 4 x sehari dalam 1
jam
•Inj transamin 3x500 mg
iv
•Inj vit k 3x10 mg iv
•N-Acethylsistein 3x200
mg po
•Atrovastatin 1x20 mg po
•Bisoprolol 1x2,5 mg po
•Ramipril 1x1,25 mg po
•Fluid balance