duty report 20 dec

8/12/2019 Duty Report 20 Dec

1/19

JANUARY 3 th 2014


2/19

CC : Epigastric pain increase since 3 days ago

Present illness history: Epigastric pain increase since 3 days ago, especialy

midnight

History of maag since 5 years ago, uncontrolled and never

to endoscopy Fever since 1 weeks ago,no High, intermitten, no

shivering, no sweat

Breathlessness (-)

Cough to day , no sputum, no blood Nausea (+) since 3 days ago and vomite to day, frequent :

2-3 x/days, consist what ate, volume -1/2 glass, no blood

Decrease of appetite (+) since 1 weeks ago

Defecate and urinate usual


3/19

Consc : fully alert

BP : 120 /80 mmHg

HR : 88 x/

RR : 20 x/

T : 37 0 CEye : Conjuctiva anemic (-),sclera icterus (-)

Neck : JVP 5-2 mmHg

Lung : Brochovesiculer, rales (+/+) wet, Whezzing (-/-)

Heart : ictus was palpable 1 finger medial of LMCS RIC V

Abdomen: Liver and spleen unpalpable, epigastric pain (+)

Ext : Fisiology reflex :(+)/(+) Normal

Pathology reflex:(-)/(-) Normal Edem (-)/(-)


4/19

Hb : 12,7 gr/dl

Leu : 11.700/mm3

Ht : 36 %

Trombosit : 276.000 /mm3Na : 132 mmol/L

K : 3,4 mmol/L

RBG : 105 mg/dL

Ureum : 13 mg/dLCreatinin : 0,8 mg/dl


5/19

WD/:

Dyspepsia like ulcer type

Community acqueried Pneumonia (CAP)


6/19

Rest/ Gastric diet II

IVFD NaCl 0,9 % 8 hrs/kolf

Prosogan inj 1 x 1 vial (IV)

Ceftriaxon inj 1 x 2 gr ( ST )Sukralfat syr 3 x cth 1

Domperidon 10 mg (if needed)

PCT 500 mg ( if needed)


7/19

Lung X-ray

Gastroscopy

Culture sputum


8/19

CC : Breathlessness increase since 1 days ago

Present illness history: Breathlessness increase since 1 weeks ago. Its felt since

2 days ago, increase with activity and no influence weather

and food

Breathlessnes felt on sleep History of wake up midnight cause by short breath

Cough since 3 months ago, white sputum, no blood

Headache since 1 days ago

History HT since 1 years ago, uncontrolled, and no drinkdrugs

Fever (-)

Urinate unsatisfy and not fluent since 3 months ago.

Urinate stone exit and sand (-)


9/19

Consc : fully alert

BP : 210/90 mmHg

HR : 96 x/

RR : 32 x/

T : 37 0 CEye : Conjuctiva anemic (+),sclera icterus (-)

Neck : JVP 5+0 mmHg, massa size 1,5x2x2 cm,soft,mobile

Lung : Bronchovesiculer, rales (+/+) wet, Whezzing (-/-)

Heart : ictus was palpable 1 finger lateral of LMCS RIC VI,reguler rythm, Murmur (-)

Abdomen: Liver and spleen unpalpable




10/19

Hb : 8,2 gr/dl

Leu : 11.700 /mm3

Ht : 24 %

Platelet : 391.000 /mm3Sodium : 137 mmol/L

Potasium : 3,5 mmol/L

Ureum : 189 mg/dL

Creatinin : 12,4 mg/dLCCT : 4,46


11/19

WD/:

CKD stage V CbCHF fc. II LVH RVH sinus rythm Cb ASHD

Community acquired pneumonia


12/19

Rest/ Low protein diet 50 gr/ Low salt II/Heart diet II/ O2 3l/1 IVFD NaCl 0,9 % 12 hrs/kolf

Ceftriaxone inj. 2 x 1 gr ( skin test )

Lasix inj. 1 x 1 amp

Azitromycin 1 x 500 mg

Candesartan 1 x 8 mg

Ambroxol syr. 3 x cth 2

Curcuma 3 x tab 1Apply Folley catheter - Fluid Balance


13/19

Lung X-ray and BNO Exp.

Sputum culture


14/19

CC : Fever since 2 days before admission

Present illness history: Fever since 2 days before admission , high, continue,

intermitten with shivering and no sweat

Cough since 4 months ago, Brethlessness (-)

Previously last 5 day of patient suffer diarrhoea, frequent 5x/day, Vol. 1 glass/diarrhea

Nausea (+) and vomite (-)

Pain of Both genue since 1 months ago

History of rheumatic drugs from healthcare (+) waist pain since 1 weeks ago, repaired pain to stomach

intermitten

Urinate usual and Pain (+)

Defecate wateryly 1 this day, frequent 1 x


15/19

Consc : fully alert

BP : 130 /80 mmHg

HR : 112 x/

RR : 32 x/

T : 39,5 0 CEye : Conjuctiva anemic (+),sclera icterus (-)

Neck : JVP 5-2 mmHg

Lung : BronchoVesiculer, rales (+/+) , Whezzing (-/-)

Heart : ictus was palpable 1 finger medial of LMCS RIC V,

reguler rythm, Murmur (-)

Abdomen: Liver and spleen unpalpable




16/19

Hb : 7,8 gr/dl

Leu : 2.200/mm3

Ht : 32 %

Platelet : 165.000 /mm3RBG : 117 mg/dL

Na : 139 mmol/L

K : 4 mmol/L

Ureum : 31 mg/dLCreatinin : 1,1 mg/dL


17/19

WD/:

Sepsis Cb BPBilateral lung tuberculosis

Moderate anemic microcytic hypocrome Cb

Chronic disease


18/19

Rest/ Soft diet / O2 2 L/1

IVFD NaCl 0,9 % 6 hrs/kolf

Ceftriaxone inj. 1 x 2 gr ( skin test )

Ciprofloxacin inf. 2 x 200 mg (iv)Continue OAT drugs

PCT 3 x 500 mg(if necessary)

Ambroxol syr. 3 x 1 cth

Fluid Balance


19/19

Lung X-ray Exp.

Culture sputum

duty report 20 dec

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