JANUARY 3 th 2014

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

Consc : fully alert BP : 120 /80 mmHg HR : 88 x/ RR : 20 x/ T : 37 0 C Eye : 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 (-)/(-)

Hb Leu Ht Trombosit Na K RBG Ureum Creatinin

: 12,7 gr/dl : 11.700 /mm3 : 36 % : 276.000 /mm3 : 132 mmol/L : 3,4 mmol/L : 105 mg/dL : 13 mg/dL : 0,8 mg/dl

WD/:

Dyspepsia like ulcer type Community acqueried Pneumonia (CAP)

 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)

Lung X-ray Gastroscopy Culture sputum

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 drink drugs Fever (-) Urinate unsatisfy and not fluent since 3 months ago. Urinate stone exit and sand (-)

Consc : fully alert BP : 210/90 mmHg HR : 96 x/ RR : 32 x/ T : 37 0 C Eye : 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 Ext : Fisiology reflex :(+)/(+) Normal Pathology reflex:(-)/(-) Normal Edem (-)/(-)

Hb Leu Ht Platelet Sodium Potasium Ureum Creatinin CCT

: : : : : : : : :

8,2 gr/dl 11.700 /mm3 24 % 391.000 /mm3 137 mmol/L 3,5 mmol/L 189 mg/dL 12,4 mg/dL 4,46

WD/:
CKD

stage V Cb CHF fc. II LVH RVH sinus rythm Cb ASHD Community acquired pneumonia

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 1 Apply Folley catheter - Fluid Balance

Lung X-ray and BNO Exp. Sputum culture

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 5 x/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

Consc : fully alert BP : 130 /80 mmHg HR : 112 x/ RR : 32 x/ T : 39,5 0 C Eye : 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 Ext : Fisiology reflex :(+)/(+) Normal Pathology reflex:(-)/(-) Normal Edem (-)/(-)

Hb Leu Ht Platelet RBG Na K Ureum Creatinin

: : : : : : : : :

7,8 gr/dl 2.200/mm3 32 % 165.000 /mm3 117 mg/dL 139 mmol/L 4 mmol/L 31 mg/dL 1,1 mg/dL

WD/:
Sepsis

Cb BP Bilateral lung tuberculosis Moderate anemic microcytic hypocrome Cb Chronic disease

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
Rest/

 Lung

X-ray Exp. Culture sputum