Lapjag 22 Novembber 2016 Hans

CC: Waist pain increase since 1 week ago
Present Illness History:

Waist pain since 1 month ago, referred to front
Fever since 4 days ago, high, no chill, no sweat
Cough since 2 days ago, schlemm +, blood -
Micturition no blood, no pain
Defecation normal
Patient has been ward in RSUD Sungai Dareh
GA:moderate ,Consc:CMC ,BP: 160/90 mmhg
,Pulse: 100/m ,RR: 24/m ,T : 37,4 C
Eyes: anemic (+/+), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: bronchovesicular, ronki +/+ ,wh-/-
Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin RIC V
Percution : cardiomegali (-)
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable, ballotement -
Percussion :tympani
Auscultation :bowel sound +
Back: CVA pain +/+
Ext: physiologic reflect +/+, oedem -/-
Hb 9.6 g/dl
Ht 32 %
Leucocyte 21.030/ul
Trombocyte 176.000/ul
RBG 81 mg/dl
Ureum 136 mg/dl
Creatinine 3,5 mg/dl
Na/K 143/3,1
pH 7.38
pO2 64
pCO2 30
HCO3- 17.7
Beecf -7.4
SO2 92
WD/: CKD stg V cb PNC
Bronchopneumonia (HAP) with severe hypoxemia
Mild anemia microcytic hypochrome cb chronic disease
Hipertension Heart Disease
Th/: Rest/Low Protein 48 gr Low Salt II/02 10 lpm via NRM
IVFD EAS Primmer 500 cc 12 jam/kolf
Inj Cefriaxone 1x2 gr
Amlodipin 1x5 mg
Candesartan 1x8 mg
Tramadol 2x50 mg
Folic acid 1x5 mg
Bicnat 3x500 mg
Nebu farbivent/6 hours
Catheter-Fluid Balance
MCV/MCH/MCHC, SI, TIBC, Feritin
Sputum culture
Renal USG
CC: Breathlessness increase since 1 day ago
-Breathlessness since 1 week ago
Hystory of pharyngytis when young adulthood
Pale since 1 month ago
Micturition decrease since 1 week ago
GA: mild, Consc: CMC, BP:120/90 mmhg
,Pulse: 98/m ,RR: 28/m ,T : 37 C
Eyes: anemic (+/+), icteric (-/-)
Lung:
Percussion:sonor
Auscultation: bronchovesicular, rales +/+ , wh-/-
Cor:
Palpation : ictus cordis 1 finger lat LMC sin RIC V
Percution : cardiomegali (+)
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable, ballotement -
Percussion :tympani
Back: CVA pain -/-
Ext: physiologic reflect +/+, oedem -/-
Hb 6.7 g/dl
Ht 19 %
Leucocyte 13.940/ul
Trombocyte 401.000/ul
RBG 114 mg/dl
Ureum 666 mg/dl
Creatinine 37,9 mg/dl
pH 7,20
pCO2 14 mmHg
pO2 90 mmHg
HCO3- 5,5
Beecf -22,5
SO2 95%
Na/K 126/7,6
SGOT/SGPT 17/21
WD/: CKD stg V cb GNC with metabolic acidosis & hypercalemia
Bronchopneumonia duplex (CAP)
Moderate anemia microcytic hypochrome cb chronic disease
Hyponatremia cb hemodilution
CHF Fc II LVH RVH sinus rhytm cb CKD
Th/: Rest/Low protein 48 gr/02 5 lpm
IVFD EAS Primmer 500 cc/24 hours
Inj Ceftriaxone 1x2 g
Nebu farbivent/8 hours
Drip insulin 10 U in D40% 2 FL
Kalitake 3x1 sacchet
Folic acid 1x5 mg
Inj Ca gluconas 1x1 amp
Bicnat 3x500 mg
Meylon correction 200 meq in 200 cc NaCl 0.9% in rapid
Planning:
Renal USG
Sputum culture
MCV/MCH/MCHC
SI, TIBC, Ferritin
Echocardiography
CC: Decrease of conciousness since 3 hours ago
Decreaseof conciousness slowly. Patient has
decrease of appetite since 1 month ago.
Fever since 1 week ago, high, no chill & sweat
Cough since 1 week ago, white schlemm, no blood
Palpitation since 1 day ago.
Chest pain -
GA: mild,Consc: somnolen,BP: 120/80 mmhg
,Pulse: 120/m ,RR: 26,T : 38 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Palpation: right fremitus =left fremitus
Percussion: sonor
Auscultation: bronchovesicular, ronchi +/+, wheezing
-/-
Cor:
Palpation : ictus cordis 1 finger med LMC sin
Percution : cardiomegaly -
Auscultation : rhytm irreguler, heart sound normal
Abd:
Inspection : flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Ext: physiologic reflect +/+
Hb 10,7 g/dl
Ht 31 %
Leucocyte 22.800/uL
Trombocyte 144.000/uL
RBG 17 mg/dl
Ur/Cr 32/0,95
SGOT/SGPT 28/19
WD/: - Decrease of conciousness cb hypoglicemia ec
low intake
- Bronchopneumoniae (CAP)
- AF NVR
Th/-Rest/Free Diet 24 hours->Heart Diet II/ O2 3 lpm
-IVFD NaCl 0,9% 8 hours/kolf
-Check RBG/15 minutes, if
RBG<60 mg/dl: D 40% 2 fl
RBG 60-80 mg/dl: D 40% 1 fl
-If RBG 3x >100 mg/dl, check RBG/hours
-If RBG 3x>100 mg/dl, check RBG/4 hours
-If RBG 100-200 mg/dl->IVFD D5% 8 hours/kolf
-If RBG >200 mg/dl->IVFD NaCl 0,9% 8
hours/kolf
-Inj Cefoperazone 2x1 g -Paracetamol 3x500 mg
-Bisoprolol 1x 5 mg
-Catheter-Fluid balance
Planning:
-BUF routine
-Sputum culture
CC: black vomite since 1 days ago
-Black vomite since 1 day ago, vomite 3 times,
glass/day
-Black stool since 1 day ago, 4 times,
glass/times
-Pain on epigastric since 3 days ago, no reffered
pain
GA:mild ,Consc:CMC ,BP:110/70 mmhg, Pulse:
92/m ,RR: 20/m ,T : 36.1 C
Lung:
Percussion: sonor
Auscultation:vesicular, ronchi -/-, wh -/-
Cor:
Percution : heart size normal
Abd:
Inspection :flat
Palpation : liver palpable 3 fingers under arc costae
Percussion :tympani
Hb 10 g/dl
Ht 31%
Leucocyte 7200/uL
Trombocyte 64000/uL
SGOT 56 u/l
SGPT 33 u/l
Ureum 48 mg/dl
Creatinine 0.8 mg/dl
WD/: -Hematemesis melena cb gastropathy NSAID
-Hepatoma
Th/:
-Rest /NGT 8 hours-> Gastric diet I
-Prosogan 2 amp -> drip prosogan 2 amp in 500 cc NaCl 0.9%
12 hours/kolf
- Sucralfat 3xC 1
-Curcuma 3x1 tab
-Domperidone 3x10 mg
-Fluid balance-Cathether urine
CC: Nausea since 6 hours ago
- Nausea since 6 hours ago, no vomit
- Previously headache 6 hours ago
- Previously pasien consume 10 eggs sleepy
drugs, 15 bodrex & baygon
- Patient look depression since 2 weeks ago.
- No breathlessness
GA: severe,Consc: somnolen,BP:120/70 mmhg
,Pulse: 90/m ,RR: 22/m ,T : 37 C
Lung:
Percussion:sonor
Auscultation:vesicular, ronki-/- , wh-/-
Cor:
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Hb 13,9 g/dl
Ht 42%
Leucocyte 10300/uL
Trombocyte 282000/uL
Na/K/Cl 140/3.3/105
RBG 109 mg/dl
Ureum 10 mg%
creat 0.8 mg%
WD/:-Bodrex intoxication
-Severe deprsion with temptamen
Th/: -Rest/Open NGT->fasting 8 hours
-IVFD EAS Pfrimmer: NaCl 0.9%= 1:1 500 cc/12 hours
-Meylon correction 200 meq in 200 cc NaCL 0.9%
-Inj lasix 2x1 amp Alinamin F 2x1 amp
-Ceftazidime 2x1 gram Ca.Gluconas 1 amp (extra)
-Levofloxacin 1x 200 mg PRC tranf post lasix
-Insulin bolus 10 unit in D 40% 2 fl slow inj
-Folic acid 1x10 mg
-Candesartan 1x8 mg
-Ambroxol 3x30 mg
CC: Vomit since 4 days ago
-vomit since 4 days ago, frekuency >5 x/days, 1/2
glass /vomit, no bleeding. Patient had consumed
anti tuberculosis drug since 8 days ago
-cough since 3 months ago
- Fever since 1 month ago
- Decrease of body weight since 1 years ago
GA: mild,Consc: cmc,BP:110/80 mmhg ,Pulse:
88/m ,RR: 22/m ,T : 37.6 C
Lung:
Palpation:right fremitus increasis > left fremitus
Percussion: dullness
Auscultation:bronchovesicular, rales +/+ , wh-/-
Cor:
Abd:
Inspection :flat
Palpation : liver palpable 1 finger under arcus
costarum , blunt edge, flat, dullness & lien
unpalpable
Percussion :tympani
HB 11.4g/dl
HT 35%
Leucocyte 7700/uL
Trombocyte 578000/uL
Na/K/Cl 138/3.8/107
RBG 102 mg/dl
ureum 22
creatinin 0,6
WD/: Drug induced liver injury ec anti tuberculosis drug
Bilateral lung tuberculosis (in therapy)
Trombositosis reactive
dd/ dispepsia syndrome dismotility type
trombositosis essential
Th/: -Rest/liver diet II
-IVFD NaCl 0,9%:D5% 1:1 6 hours/kolf
-stop anti tuberculosis drug
-inj ondansetron 3 x 4 mg
-Curcuma 3 x 1 tab
- Ambroxol syr 3 x c1
p/ ceck liver fungtion
Ceck marker hepatitis

Lapjag 22 Novembber 2016 Hans

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CC: Waist pain increase since 1 week ago

Present Illness History:

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