Morning &

Duty
Report
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

 Mushthafa/Male/ 41 y.o /HCU-20

Chief Complaint:
• Decrease of conciousness since
1
1 days ago
Present Illness History

• Decrease of conciousness since 1 days ago, slowly. At the first patient can
communicated then patient looked sleepy and difficult to communicated.
There is no head injury and seizure.
• Breathlessness since 3 days ago, no influence by activity, food, and weather.
Sleep with one pillow.
• Cough since 5 days ago, sputum (+), blood (-), but now no blood
• Fever since 7 days ago. But now, there is no fever.
• Decrease of appetite since 1 week ago
• Nausea and vomiting since 3 days ago, 3x/day, consist the meal. No black and
blood vomite
• Micturition was decrease than before
• Defecation is normal
• Lump in neck increase since 2 years ago
• Patient was known have Nasopharyngeal carcinoma since 1 month ago and
got 1st chemotheraphy 5 days ago
Past Illness History

• No History of hypertension
• No history of diabetes mellitus

Family Illness History

• No Family had symptoms like this

patient
Physical Examination

• General Appearance : Severe

• Consciousness level : somnolen

• BP : 107/70 mmHg
• HR : 80 x/minute
• RR : 24 x/minute
•T : 36,9 º C
• SaO2 : 98% on O2 10 L/mnt via NRM
• Eye
– Conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: symetric at static and dynamic
– Palpation: can not asses
– Percussion: sonor
– Auscultation: br.vesicular, rhonchi +/+, wheezing -/-
• Cor: VII
–Inspection : ictus is not seen
–Palpation : ictus is palpated at 1 finger
medial LMCS ICS V
–Percussion:
•Upper border: ICS II
•Right border: linea sternalis dextra
•Left border : 1 finger medial LMCS ICS V
–Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-), collateral vein (-)
– Palpation: liver and spleen unpalpable
– Percussion: shifting dullness (-)
– Auscultation: bowel sound (+) normal

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
– Palmar erythema -/-
 Items Value
Laboratory Hb 10,2 gr/dl
Ht 26 % VII
WBC 8.640 /mm3
Platelet 343.000
Diff. Count 0/1/0/87/8/4
PT/APTT 11,9/37,2
RBG 100
Ur/Cr 41/0,9
Alb/Glb 3,3/5,3
SOGT/SGPT 152/36
Na/K/Cl 99/2,7/61
BGA 7,56/15/185/13,4/-8.8/
Chest X-Ray VII
ECG VII
Problems
• Decrease of consciousness
• Breathlessness
• Hyponatremia
• Nasopharyngeal carcinoma
Working Diagnosis
• Decrease of conciousness c.b Hyponatremia
• Sepsis c.b Community Acquired Pneumonia severe high risk MDR
• Community Acquired Pneumonia
• Nonkeratinizing Nasopharyngeal carcinoma St IVa (T3 N3 M0) on
chemotheraphy
• Sindrom dyspepsia dysmotility type
• Hyponatremia cb Low Intake
• Hypokalemia cb low intake
• Liver function disorder cb sepsis
Differential Diagnosis
• Decrease of conciousness c.b septic associated
encephalopathy
Therapy
• Rest/ liquid diet 4x250 cc via NGT
• O2 10 L/I via NRM
• IVFD NaCl 3 % in 12 hours/kolf (3 kolf)
• Inj. Ceftriaxon 2x1 gr IV
• Inf. Levofloxacin 1x750 mg IV
• Drip KCl 25 mEq in 200cc NaCl 0,9% in 4 hours
• Paracetamol 3x500mg
• Asetilcistein 3x200mg
• Lansoprazol 1x30mg
• Domperidon 3x10mg
• KSR 3x600mg
• UDCA 3x250mg PO
Plan
• Urinalysis
• Culture Sputum, blood culture
• Check procalsitonin
• Liver USG