Duty report

January 18th, 2018

Ramadansyah, Male, 89yo,

Chiefcomplain
Change of consciousness since 2
day ago
 Present illness history
◦ Change of consciousness since 2 day ago. Patient
looks apaty and cannot communicate with the other
and sometimes looks sleepy
◦ breathlessness since 1days ago. Not affected by
activity, weather & food. Sleep with elevated pillow (-),
wake up at night cause breathlessness (-)
◦ Fever since 2 days ago, not high & not shivering and
not sweating a lot
◦ Cough since 2 days ago accompanied by sputum
◦ Swolllen both of the leg since 4 months ago
◦ Nausea & vomiting (-)
◦ Defecating & urinating was normal
◦ Hystory of hypertension and DM (-)
◦ Patient had been suffer TB 10 years ago and get
medicine 6 months and recover

12/03/18
Physical Examination
level of consciousness : Delirium

BP : 130 / 80 mmHg

HR : 78 x/minute

RR : 28 x/minute

T: 37,7 oC
 Eye
◦ Conjunctiva are anemic -/-
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation : Bronchovesicular, Rh +/+ at basal both of the
lung, Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medial LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur (-)
 Abdomen:
◦Inspection: Enlargement (-)
◦Palpation: liver and spleen not palpable
◦Percussion: tympani
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema -/-
Laboratory
Examination Result
Hb 14,3
Leukosit 4270
Trombosit 154.000
Hematokrit 44
GDS 156
Ur / Cr 80 / 1,4
Na / K /cl 141 / 4,5 / 106
Ph 7,374
Pco2 47,6
po2 77,6
Hc03- 28
Beecf 2.6
s02 94,8

12/03/18
12/03/18
Working Diagnose
Acute Confusional state
Bronchopneumonia dupleks
(CAP) with hypoxemia
AKI rifle R ec prerenal ec
dehidration
Lapsed TB
Therapy
 Ist / Liquid diet 6x200 cc via NGT / O2 5 L / I
 IVFD Nacl 0.9 % 6 hr/kolf
 Ceftriaxone 2x1 gr
 azitromicin 1 x 500 mg
 Paracetamol 3 x 500 mg
 Nebu flumucyl/8 hr
 Fluid balance
plan
Expertise
x-ray
Sputum culture

12/03/18