Mrs.

R/ 57 YO
CC : loss of consciousness
Findings

Assesment

loss of consciousness, loss of appatite,

immobilitation
GCS: E1V1M1, TD: 110/70, PR : 92x, T : 36oC,
RR: 16x
Eye: Pale Conjungtiva (+), Sclera icteric (-)
THT: Normal
Neck: Lymph Nodes not Enlarged
JVP: vein not distended
THRORAX
I : Symmetrical chest wall movement, ictus cordis
(-)
Pal: Symmetrical Vocal fremitus increase in sinistra
lung, ictus cordis : palpable
Per: Sonor/Sonor , cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi +/+,
wheezing -/-, amforik -/-. S1 and S2 reguler,
gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+)
Pal : Pressure pain (+).
Per : Timpani, percussion tenderness (+)
Extremitas : pitting oedem (-), warm acral, CRT <
2, turgor normal, gangren on left leg

Loss of
conscioune
ss e.c
hypoglicem
ic
Hypernatre
mia
Anemia
Hipoalbumi
nemia
Foot
diabeticum
Riw. CVD.
SNH

Therapy
1. IVFD : I NS 3%/24 hours
III Dextrose
10%/24 hours
2. O2 : nasal canul 2-3 lpm
3. Smooth diet, doesnt
stimulate, DM 1900 kkal
4. MM/
KSR 3x1 tab
Hemobion 3x1 tab
Metronidazole 3x500 iv
Ceftizoxime 2x1 gr iv
Simvastatin 1x20mg

Planning
1. Hospitalized
2. IVFD
I NS 3% / 24 Hours
III Dextrose 10%/24 hours
3. Raber with dr. Tumpal Sp.
S
4. Check GDS/ 3 hours
5. Check SGOT, SGPT