CC: Breathlessness increase since 1 day ago

Present Illness History:

Brethlessness increase since 1 day ago.
Brethlessness since 1 week ago
Breathlessness not influence by activity, season,
food
Cough since 1 week ago, schlemm +, blood -
Fever since 1 week ago, high, no chill, no sweat
Patient has diagnose Malaria Vivax, get therapy 3
weeks ago
 GA: Mild,Consc: CMC,BP: 100/50 mmhg ,Pulse:
100/m ,RR:30/m ,T : 39 C
Eyes: anemic (+/+), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: bronchovesicular, ronchi+/+,wh-/-
 Cor:
Inspection :ictus cordis not found
Palpation :ictus cordis 1 finger medial LMC sin
Percussion : cardiomegaly -
Auscultation : regular rhytm
Abd:
Inspection : convex
Palpation : liver & spleen unpalpable
Percussion : tympany
Auscultation : bowel sound +
Ext: edema -/-, fisiologic reflect +/+
Hb 9.3 g/dl
Leucocyte 6.850/ul
Ht 26 %
Trombocyt 181.000/uL
Na 131 mmol/l
K 2,1 mmol/l
Ca 6,4 mg/dl
RBG 103 mg/dl
Malaria -
Ur/Cr 68/1,8
pH 7,41
pCO2 18 mmHg
pO2 56 mmHg
HCO3- 11,4 mmol/l
BEecf -13,2 mmol/l
SO2 89%
WD/:
Bronchopneumonia duplex (CAP) with hipoxemia
AKI RIFLE R cb prerenal cb dehydration
Hypocalemia et hypocalsemia
Mild anemia cb chronic disease DD/Malaria
Post Therapy Malaria Vivax
Th/:
-Rest/High Calorie High Protein Diet/O2 10 lpm via NRM
-IVFD Na Cl 0.9 % 6 hours/kolf
-Inj Ceftriaxone 1x2 g
-KCL correction 30 meq in 200 cc NaCl 0,9 % in 4 hours
-Nebu farbivent/8 hours
-Nebu fluimucyl/8 hours
-Osteocal 2x1000 mg
-Paracetamol 3x500 mg
-Catheter-Fluid Balance
 Planning:
Sputum culture
MCV/MCH/MCHC
 CC: cough increase since 1 day ago
Present Illness History:
Cough increase since 1 day ago. Cough since 3
days ago, schlemm +, no blood
Fever increase since 3 days ago, high, no chill
& sweat. Now no fever.
Hystory of diabetics since 3 years ago
Patient fall from bathroom 4 days ago
 GA:mild ,Consc:CMC ,BP: 120/80 mmhg ,Pulse:
80/m ,RR: 20/m ,T : 36.5 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
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedem -/-
HB 9.3 g/dl
HT 28 %
Leucocyte 5000/ul
Trombocyte 94.000/ul
Na 126 mmol/l
K 3.2 mmol/l
WD/: Bronchopneumonia duplex (CAP)
Contusio + suspect ligament rupture et patella
Hyponatremia cb low intake
DM type 2 controlled diet normoweight
Suspect ITP
Mild anemia microchytic hypochrom cb chronic disease
Th/: Rest/DD 1700 kcal
IVFD NaCl 0.9 % 8 hours/kolf
Inj Ceftriaxone 1x2 gr IV
Paracetamol 3 x500 mg
Ambroxol 3x C1
 CC: decrease of conciousness since 1 day ago
Present Illness History:
-Decrease of conciousness since 1 day ago
Cough since 2 days ago, schlemm +
Fever since 1 hour ago, not high, no chill, no
sweat
Hypertentsion history since 1 year ago
Micturition & defecation normal
 GA: mild, Consc: delirium, BP:160/80 mmhg
,Pulse: 96/m ,RR: 24/m ,T : 37.8 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: bronchovesicular, rales +/+ , wh-/-
 Planning:
Exp Ro Thorax
MCV/MCH/MCHC
SI, TIBC, Ferritin
Sputum culture
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : cardiomegaly -
Auscultation: regular, murmur -
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedem -/-
HB 13.2 g/dl
HT 39%
Leucocyte 5900/uL
Trombocyte 174.000/uL
Ur 16 mg/dl
Cr 1 mg/dl
WD/:
-Delirium Acute Syd
-Bronchopneumonia
-Hypertention stg II cb esential
-Ischemic myocard lateral
Th/:
-Rest/Soft Diet/O2 5 lpm -Ascardia 1x80 mg
-IVFD NaCl 0.9% 8 hours/kolf -Lanzoprazole 1x30 mg
-Ceftriaxon 1x2 gr
-Azithromicin 1x500 mg
-Ambroxol 3x cth 2
-Paracetamol 3x2
-Sohobion 1x1
-Amlodipin 1x 10 mg
-Candesartan 1x 8 mg
 CC: breathlessness since 2 days ago
Present Illness History:
Breathlessness since 2 days ago
Cough since 5 days, yellow schlemm, no blood
Decrease of appetite since 2 days ago
Headache since 2 days ago
 GA: mild,Consc: somnolen,BP: 180/100 mmhg
,Pulse: 100/m ,RR: 28,T : 39 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation: right fremitus =left fremitus
Percussion: sonor
Auscultation: bronchovesicular, ronchi +/+, wheezing
-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : cardiomegaly -
Auscultation : heart sound normal
Abd:
Inspection : flat
Palpation : liver palpable 3 fingers under arc costae,
blunt side, lien s
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 10 g/dl
Ht 31 %
Leucocyte 7200/uL
Trombocyte 64000/uL
WD/: - Decrease of conciousness cb respiratory failure
type 1
- Septic cb bronchopneumoniae (CAP)
- Hypertention stage II cb essential
- Susp DIC
Th/-Rest/Low salt Diet II via NGT/ O2 NRM 10 lpm
-IVFD NaCl 0.9% 8 hours/kolf
-Ceftriaxon 1x2 gr
-Ciprofloxacin 2x200 mg
-Ambroxol 3x C1
-Paracetamol 3x500 mg
 Planning:
-BUF routine
-Faal Hepar
-Hepatitis marker
-AFP
-Abdominal USG
 CC: black vomite since 1 days ago
Present Illness History:
-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
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion: sonor
Auscultation:vesicular, ronchi -/-, wh -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 3 fingers under arc costae
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
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
Present Illness History:
- 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
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation:vesicular, ronki-/- , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
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
Present Illness History:
-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
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus increasis > left fremitus
Percussion: dullness
Auscultation:bronchovesicular, rales +/+ , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 1 finger under arcus
costarum , blunt edge, flat, dullness & lien
unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
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