CC: Decrease of conscioussness since 1 day ago

Present Illness History:

Decrease of conscioussness with diapheresis,
agiatation, blurred vision
History of DM, hungry & thirsty denied
Fever since 2 days ago, high, no chill, no sweat
Cough since 1 week ago, no blood, schlem +
Micturition & defecation normal
 GA: Severe,Consc: Sopor,BP: 110/70 mmhg
,Pulse: 100/m ,RR:24/m ,T : 38.2C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:fremitus hard to asesst
Percussion:sonor
Auscultation: bronchovesicular, ronchi+/+,wh-/-
 Cor:
Inspection :ictus cordis not found
Palpation :ictus cordis 1 finger medial LMC sin
Percussion : cardiomegaly -
Auscultation : regular rhytm
Abd:
Inspection : flat
Palpation : liver & spleen unpalpable
Percussion : tympany
Auscultation : bowel sound +
Ext: edema -/-, fisiologic reflect +/+
Hb 13,5 g/dl
Leucocyte 18.430/ul
Ht 41 %
Trombocyt 310.000/uL
Na 135 mmol/l
K 3,8 mmol/l
Cl 104 mmol/l
RBG 34 mg/dl
Ur/Cr 12/0,9
WD/:
Decrease of conscioussness cb hypoglicemia
Bronchopneumonia duplex (CAP)
Th/-Rest/NGT-Fluit Diet High Calorie High Protein/ O2 3 lpm
-IVFD D 10% 8 hours/kolf
-Check RBG/15 minutes, if
RBG<60 mg/dl: D 40% 2 fl
RBG 60-80 mg/dl: D 40% 1 fl
-If RBG 3x >100 mg/dl, check RBG/hours
-If RBG 3x>100 mg/dl, check RBG/4 hours
-If RBG 100-200 mg/dl->IVFD D5% 8 hours/kolf
-If RBG >200 mg/dl->IVFD NaCl 0,9% 8 hours/kolf
-Inj Ceftriaxone 1x2 g -Paracetamol 3x500 mg
-Nebu Farbivent/8 hours
-Catheter-Fluid balance
 Planning:
Fasting Blood Glucose/PP Blood Glucose
Sputum culture
 CC: gum bleeding since 1 day ago
Present Illness History:
Gum bleeding since 1 day ago. Patient get
warfarin 1x2 mg
History of breathlessness influenced by activity, not
influenced by weather & food
Patient has been known rheumatic heart disease
since 6 month ago, will get repair for valve
Micturition & defecation normal
 GA:mild ,Consc:CMC ,BP: 120/80 mmhg ,Pulse:
72/m ,RR: 23/m ,T : 36.7 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: vesicular, ronki -/- ,wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC sin RIC VI
Percution : cardiomegali (+)
Auscultation : diastolic murmur grade 4/6
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedem -/-
HB 15.1 g/dl
HT 44 %
Leucocyte 9.670/ul
Trombocyte 119.000/ul
Na 136 mmol/l
K 3.6 mmol/l
PT/aPTT >300/ >300
Ur/Cr 28/1,1
RBG 118 mg/dl
WD/: Diathesis hemorragic cb hypocoagulation cb warfarin
induced
CHF Fc II LVH RVH MS sinus rhytm cb RHD
Trombocytopenia
Th/: Rest/Heart Diet II/O2 3 lpm
IVFD D 5% 12 hours/kolf
Inj Furosemide 1x20 mg (IV)
Inj Vit K 3x1 amp
Spironolacton 1x25 mg
Bisoprolol 1x2,5 mg
Catheter-fluid balance
 Planning:
Echocardiography
INR
 CC: Disturb of sleep since 1 week ago
Present Illness History:
-Disturb of sleep since 1 week ago. Patient most
sleep in day
Micturition like tea since 4 months ago
Black vomite & black stool denied
Patient has been known cirrhosis & get
abdominal USG
 GA: mild, Consc: CMC, BP:100/60 mmhg
,Pulse: 88/m ,RR: 20/m ,T : 37 C
Eyes: anemic (-/-), icteric (+/+)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: vesicular, rales -/- , wh-/-
 Cor:
Inspection :ictus cordis not found
Palpation :ictus cordis 1 finger medial LMC sin
Percussion : cardiomegaly -
Auscultation : regular rhytm
Abd:
Inspection : convex
Palpation : liver unpalpable, spleen S 1
Percussion : shifting dullness +
Auscultation : bowel sound +
Ext: edema -/-, fisiologic reflect +/+
Hb 10,8 g/dl
Leucocyte 11.700/ul
Ht 31 %
Trombocyt 90.000/uL
Na 120 mmol/l
K 5,2 mmol/l
Cl 89 mmol/l
Ca 6,9 mg/dl
RBG 103 mg/dl
Ur/Cr 212/4
Alb/Glb 2,1/4,4
WD/: Encephalopathy hepaticum grade I
Cirrhosis hepatic post necrotic decompensated stage
Hepatorenal syndrome
Hyponatremia et hypocalsemia
Trombocytopenia cb cirrhosis hepatic
Th/: Rest/Liver Diet II/O2 3 lpm
IVFD Comafusin hepar:Triofusin= 1:1 12 hours/kolf
Correction NaCl 3 % 12 hours/kolf
Inj Ca gluconas 2x1 amp
Madopar 3x1 tab
Lactulac 3xC1
Spironolacton 1x100 mg
Curcuma 3x1 tab
Transfusion albumin 20% 100 cc
Catheter-fluid balance
 Planning:
Abdominal USG
Esofagogastroduodenoscopy
 CC: breathlessness since 2 days ago
Present Illness History:
Breathlessness since 2 days ago
Cough since 5 days, yellow schlemm, no blood
Decrease of appetite since 2 days ago
Headache since 2 days ago
 GA: mild,Consc: somnolen,BP: 180/100 mmhg
,Pulse: 100/m ,RR: 28,T : 39 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation: right fremitus =left fremitus
Percussion: sonor
Auscultation: bronchovesicular, ronchi +/+, wheezing
-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : cardiomegaly -
Auscultation : heart sound normal
Abd:
Inspection : flat
Palpation : liver palpable 3 fingers under arc costae,
blunt side, lien s
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 10 g/dl
Ht 31 %
Leucocyte 7200/uL
Trombocyte 64000/uL
WD/: - Decrease of conciousness cb respiratory failure
type 1
- Septic cb bronchopneumoniae (CAP)
- Hypertention stage II cb essential
- Susp DIC
Th/-Rest/Low salt Diet II via NGT/ O2 NRM 10 lpm
-IVFD NaCl 0.9% 8 hours/kolf
-Ceftriaxon 1x2 gr
-Ciprofloxacin 2x200 mg
-Ambroxol 3x C1
-Paracetamol 3x500 mg
 Planning:
-BUF routine
-Faal Hepar
-Hepatitis marker
-AFP
-Abdominal USG
 CC: black vomite since 1 days ago
Present Illness History:
-Black vomite since 1 day ago, vomite 3 times,
glass/day
-Black stool since 1 day ago, 4 times,
glass/times
-Pain on epigastric since 3 days ago, no reffered
pain
 GA:mild ,Consc:CMC ,BP:110/70 mmhg, Pulse:
92/m ,RR: 20/m ,T : 36.1 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion: sonor
Auscultation:vesicular, ronchi -/-, wh -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 3 fingers under arc costae
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 10 g/dl
Ht 31%
Leucocyte 7200/uL
Trombocyte 64000/uL
SGOT 56 u/l
SGPT 33 u/l
Ureum 48 mg/dl
Creatinine 0.8 mg/dl
WD/: -Hematemesis melena cb gastropathy NSAID
-Hepatoma
Th/:
-Rest /NGT 8 hours-> Gastric diet I
-Prosogan 2 amp -> drip prosogan 2 amp in 500 cc NaCl 0.9%
12 hours/kolf
- Sucralfat 3xC 1
-Curcuma 3x1 tab
-Domperidone 3x10 mg
-Fluid balance-Cathether urine
 CC: Nausea since 6 hours ago
Present Illness History:
- Nausea since 6 hours ago, no vomit
- Previously headache 6 hours ago
- Previously pasien consume 10 eggs sleepy
drugs, 15 bodrex & baygon
- Patient look depression since 2 weeks ago.
- No breathlessness
 GA: severe,Consc: somnolen,BP:120/70 mmhg
,Pulse: 90/m ,RR: 22/m ,T : 37 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation:vesicular, ronki-/- , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 13,9 g/dl
Ht 42%
Leucocyte 10300/uL
Trombocyte 282000/uL
Na/K/Cl 140/3.3/105
RBG 109 mg/dl
Ureum 10 mg%
creat 0.8 mg%
WD/:-Bodrex intoxication
-Severe deprsion with temptamen
Th/: -Rest/Open NGT->fasting 8 hours
-IVFD EAS Pfrimmer: NaCl 0.9%= 1:1 500 cc/12 hours
-Meylon correction 200 meq in 200 cc NaCL 0.9%
-Inj lasix 2x1 amp Alinamin F 2x1 amp
-Ceftazidime 2x1 gram Ca.Gluconas 1 amp (extra)
-Levofloxacin 1x 200 mg PRC tranf post lasix
-Insulin bolus 10 unit in D 40% 2 fl slow inj
-Folic acid 1x10 mg
-Candesartan 1x8 mg
-Ambroxol 3x30 mg
 CC: Vomit since 4 days ago
Present Illness History:
-vomit since 4 days ago, frekuency >5 x/days, 1/2
glass /vomit, no bleeding. Patient had consumed
anti tuberculosis drug since 8 days ago
-cough since 3 months ago
- Fever since 1 month ago
- Decrease of body weight since 1 years ago
 GA: mild,Consc: cmc,BP:110/80 mmhg ,Pulse:
88/m ,RR: 22/m ,T : 37.6 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus increasis > left fremitus
Percussion: dullness
Auscultation:bronchovesicular, rales +/+ , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 1 finger under arcus
costarum , blunt edge, flat, dullness & lien
unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
HB 11.4g/dl
HT 35%
Leucocyte 7700/uL
Trombocyte 578000/uL
Na/K/Cl 138/3.8/107
RBG 102 mg/dl
ureum 22
creatinin 0,6
WD/: Drug induced liver injury ec anti tuberculosis drug
Bilateral lung tuberculosis (in therapy)
Trombositosis reactive
dd/ dispepsia syndrome dismotility type
trombositosis essential
Th/: -Rest/liver diet II
-IVFD NaCl 0,9%:D5% 1:1 6 hours/kolf
-stop anti tuberculosis drug
-inj ondansetron 3 x 4 mg
-Curcuma 3 x 1 tab
- Ambroxol syr 3 x c1
 p/ ceck liver fungtion
Ceck marker hepatitis