duty report thurrsday may 16th 2013

8/13/2019 Duty Report Thurrsday May 16th 2013

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Cc: Swelling in chest increased since 3 months ago

Present Illness History: Swelling in chest increased since 3 months ago,size of eggs chicken,

swelling was felt since 1 year ago,initially at nut, pain (+) Swelling in the face since 3 months ago, arise suddenly,pain(-)

Breathlesness since 3 months ago, breathlesness increased if lie down anddecreased if take a seat Fever since 1week ago,not continuely,no sweat,no tremble, now no fever,

fever was felt 3 months ago Cough since 1 week ago,mucous (+),no bloody, cough was felt since 2

months ago Decrease of body weight since 1weeks

Apetite normal History of smoking since 27 years ago, 3 wrap /day History of get cancer drug (-) Vomit (-) 1 Year ago the patiens has been treatment in pulmonology department for

3 weeks


3/45

Mixturation and defecation usuall

The patients sister suffer thyroid cancer and

had been operation 1997

Physical examination:

GA: Moderate

Consc: cmc

BP: 120/70 mmHg

Pulse: 80x/min

RR: 20x/min T: 36,5 C


4/45

Eye: Conjunctiva anemis (-), Yellow greenishicteric (+)

Neck :Venectasi (+) JVP 5-2 cm H2OChest:Swelling size eggs chicken (7x5x1)cm,consistance

hard,surface flate,immobile,pain(+),pulsasion (-) Heart:normal Lung: Vesicular, Rhales (-)/(-) Abdomen

Liver and splen unpalpable Extrmities : RF (+)/(+) Normal,RP (-)/(-) NormalEdema (-)/(-)


5/45

Lab: Hb: 10,9 gr% Leuco: 18.400/mm3 Ht: 35 % Trombo: 147.000/mm3

Na/K/Cl/Ca: 122/3,3/102 mmol/L Albumin : 2,3 Total Bilirubin : 17,81 Biliirubin direk : 16 Bilirubin Indirect : 1,81

SGOT : 235 SGPT : 98 PT :26,2 APTT :75,3


6/45

WD: Tumors of Mediastinum

DD/ Bronchogenic Cancer

Lymphoma Malignum

Therapy Rest/ Daily Diet

Ambroxol Syr 3x CI

Tramadol 3x 1


7/45

Planning- Ro thorak

- Citology sputum

- CT scan thorak- TTNA


8/45

Critical Ill: Insulin 50 units dripped in 50 cc NaCl 0.9%

with syringe pump started from 1.5cc/h

Check RBG/h If RBG < 80: 0.5cc/h + D 40% 1 flacc

RBG 80-110: 1cc/h

RBG 110-160: 1.5cc/h

RBG 160-220: 2cc/h RBG > 220: 2.5cc/h + insulin bolus 8u IV


9/45

Check K/6h If K < 3.5: KCl correction 40 meq

K 3.5-4.5: 20 meq

K 4.5-5.5: 10 meq K > 5.5: -


10/45

Ambroxol syr 3xcth2 PCT 3x500mg

Amlodipine 1x5mg

Candesartan 1x8mg Folic acid 1x5mg

Bicnat 3x500mg


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12/45

Physical examination: GA: moderate

Consc: CMC

BP: 110/60 mmHg Pulse: 96x/min

RR: 23x/min

T: 37.7 C


13/45

Eye; anemic conj +/+, icteric sclera -/- Heart: cardiomegali -, murmur -

Lung: bronchovesiculer, rales +/+, wh -/-

Stomach: distension +, liver and spleen werehard to measure, shifting dullness +

Extr: edema +/+, erythema of palmar +/+,flapping tremor -


14/45

Lab: Hb: 6.3 gr% Leuco: 5000/mm3 Ht: 19 % Trombo: /mm3 PT:16.2 APTT: 44.2 D-Dimer: 1.5 Alb/glob: 2.4/2.1

SGOT/SGPT: 21/21 Bil I/II: 0.87/0.91 HBsAg -


15/45


16/45

Thy: Rest/flowing NGT fasting max 3 days hepar diet I IVFD Aminofusin:triofusin:NaCl 0.9% 1:2:1 8 h/kolf Stilamin 1 amp dripped in 50 cc NaCl 0.9%, bolus 4cc then

continue drip with syringe pump 4.1cc/h IVFD NaCl 3% 12h/kolf

Ceftriaxone vial 1x2gr Transamin amp 3x1 Vit K amp 3x1 Curcuma 3x1 Sistenol 3x1 KSR 1x1 Ambroxol syr 3xcth2 Cross match PRC tranfusion until Hb > 8gr% Klisma twice a day


17/45

Cc: pro 4thchemotherapy indicated by nonHodgkin limfoma malignant oculi dextra

Present Illness History:

Pro 4thchemotherapy indicated by nonhodgkin limfoma malignant oculi dextra

Fever

Cough

Decrease of appetite -


18/45

Physical Examination: GA: moderate

Consc: CMC

BP: 120/70 mmHg Pulse: 88x/min

RR: 20x/min

T: 36.7 C


19/45

Eye: anemic conj -/-, icteric sclera /- Pulmo: vesiculer, rh -/-, wh -/-

Cor: cardiomegali -, murmur -

Abd: liver and spleen were unpalpable Extr: edema -/-


20/45

Lab: Hb: 11.5 gr%

Leuco: 3700/mm3

Ht: 31 % Trombo: 5000/mm3

Na/K/Cl: 135/4.3/107 mg%

RBG: 106 mg%

Ur/Creat: 17/1 mg%


21/45

WD: Pro 4thchemotherapy indicated by non

hodgkin limfoma malignant oculi dextra


22/45

Therapy: Rest/soft diet high calories high protein

IVFD NaCl 0.9% 8h/kolf

PCT 500mg 3x1 NTR 2x1


23/45

Cc: diarrhea since 5 days agoPresent illness history:

Diarrhea since 5 days ago

Abdominal pain since 5 days ago Thirst (+), weak (+)

Decrease of appetite since 5 days ago

Nausea +


24/45

Physical Examination: Vital sign : GA : moderate; blood pressure

110/70; pulse 90x; T: 36.7 ; RR : 22x

Eyes :anemic conj -/-, icteric sclera -/-

Lung: vesiculer, rales -/-, wh -/-

Heart: cardiomegali -, murmur

Stomach: liver and spleen were unpalpable

Daldiyono score: 1


25/45

Lab: Hb: 16.7 gr%

Leuco: 8400/mm3

Trombo: 251000/mm3 Ht: 48%

Na/K/Cl: 138/3.9/105 mmol/L

RBG: 88 mg%

Ur/creat: 24/1.1 mg%


26/45

WD: Acute gastroenteritis colliform type without

dehydration


27/45

Thy: Rest/soft diet low fiber

IVFD NaCl 0.9% 8h/kolf

PCT when needed NTR 2x1

Oralit when needed


28/45

Cc: fever since 2 weeks ago

Present Illness History:

Fever since 2 weeks ago Headache since 2 weeks ago

Nausea since 2 weeks ago

Fatigue since 2 weeks ago


29/45

Physical examination: GA: moderate

Consc: CMC

BP: 130/70 Pulse: 110x

RR: 22x

T: 38 C


30/45

Eye: anemic conj -/-, icteric sclera -/- Lung: vesiculer, rh -/-, wh -/-

Heart: cardiomegali -, murmur

Stomach: liver and spleen were unpalpable Extr: edema -/-


31/45

Lab: Hb: 12.4 gr% Ht: 39% Leuco: 10700/mm3 Trombo: 178000/mm3 Na/K/Cl: 129/3.2/95 mmol/L RBG: 115mg% Ur/creat: 20/1 mg% S. tyhphii H: 1/80 S. thyphii O: 1/80


32/45

Wd: Susp Malaria


33/45

Thy: Rest/daily diet

IVFD RL 6h/kolf

PCT 3x500mg NTR 2x1

Domperidone 10mg 3x1


34/45

Cc: increase of breathlessness since 2 daysago

Present illness history:

Increase of breathlessness since 2 days ago

Cough since 3 months ago

Mixturation frequence decreased since 3

months ago Diabetic history since 15 yrs ago


35/45

Physical examination: Consc: CMC

GA: moderate

BP: 160/100 Pulse: 82x

RR: 24x

T: 36.2 C


36/45

Eye: anemic conjunct +/+ Lung: bronchovesiculer, rales +/+

Ext: edema +/+


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39/45

WD/ Stage V CKD cb nephropathy DM with

metabolic acidosis

BP duplex (CAP) with type I respiratory failure

Type II DM controlled by diet normoweight +necrotic digiti I pedis dextra

Pulmonary TB

Bilateral pleural effusion cb specificDD/ cb hypoalbuminemia


40/45

Thy: Rest/soft diet DD 1700 kkal low salt II low protein 40

gr/NRM 10 L/1 IVFD Easpfrimmer 500 cc/24h Lasix amp 1x1 Ceftriaxone vial 1x2gr Folic acid 1x5mg Amlodipine 5mg 1x1 Candesartan 8mg 1x1 Ambroxol syr 3xcth2 Cross match PRC tranfusion post lasix until Hb > 10gr% Meylon correction 150 mg in 150 cc naCl 0.9% fast drip


41/45

Cc; epigastric pain since 1 week ago

Present illness history:

Epigastric pain since 1 week ago

Cough since 1 week ago

Fever since 3 days ago

Hypertension history since 1 month ago


42/45

Physical examination Consc: CMC

GA: moderate

BP: 160/80pulse; 80x

RR: 21x

T: 36.8

Lung: bronchovesiculer, rales +/+


43/45

Lab: Hb: 10.2

Leuco: 13600


44/45

WD/ Gastropathy NSAID DD/ gastric ulcer

CAP Geriatric

Stage II Hypertension cb essensial


45/45

Thy: Rest/low salt II gastric diet II/O2 5 L/1 IVFD D5% 8h/kolf Ceftriaxone vial 1x2gr Azythromicine 1x500mg Ozid amp 1x1 Sucralfat syr 3xcth2 Ambroxol syr 3xcth2 Amlodipine 1x5mg Candesartan 1x8mg

duty report thurrsday may 16th 2013

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