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April 26th ,2016

dr. Rangga
Suhayati, Female, 61yo, HCU02

 Cc:

 Decreased of conciousness since 4 hours ago

 Present Illness History


 Decreased of conciousness since 4 hours ago, slowly, initially patient
looked sleep and can’t communication.
 Fever since 1 day ago, high, continously, no chill and no exessive
sweating.
 Cough since 3 days ago, sputum, bloody cough (-)
 Breathlessness since 2 days ago. Not Affected by activity.
 No fever
 Patient had been done hospitalized in muaro bungo hospital and
then referred to M. Djamil Hospital.

Past Illness History
• History of HT (-)
• History of DM (+) since 14 years ago, uncontrolled

Family Illness History


• Nothing family with the same of diasease
Physical Examination

 Consciousness level : sopor

 BP : 170/90 mmHg

 HR : 136x/minute

 RR : 26x/minute

 T: 39,2 C
 Eye
 Conjunctiva are anemic +/+
 Sclera are icteric -/-

 Neck
 JVP 5-2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: left = right fremitus
 Percussion: sonor
 Auscultation: Bronchovesicular, rales +/+, wheezing -/-
 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 1 finger medial LMCS RIC V
 Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen: 
 Inspection: enlargement (-)
 Palpation: Liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+) normal

Extremities:
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema -/-
Laboratory

Hb 9,6 gr/dl
Ht 21%
WBC 21.800/mm3
Platelet 214.000/mm3
RBG 395 mg/dl
Na/K/Cl/Ca 131/2,9/78/8,0
Ur/Cr 107/7
Working Diagnosis

 Decreased of conciousness cb septic related
enchefalopathy
 Bilateral bronchopneumonia (HAP)
 Acute on CKD
 Hipertension stage II cb Essential
Therapy

 Rest/Liquid Diet via NGT 6 x 200cc DD 1700 kkal/ O2 3L/1’
 IVFD NaCl 0,9% 4 hours/colf
 inj. Cefoperazone 2 x 1gr (iv)
 Inf. Levofloxacine 1 x 500mg (iv)
 Paracetamol tab 3 x 500mg (po)
 N-acetylsistein tab 3 x 200mg (po)
 Amlodipin tab 1 x 5mg (po)
 Candesartan tab 1 x 8mg (po)
 Drip critical ill
 Correction of meylon 200 mEq

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