DUTY REPORT


November 14th ,2017

dr. Rudi Erwin

 Suardi, Male, 75yo, MW21

 Cc:

 Decreased of conciousness since 3 days ago

 Present Illness History

 Decreased of conciousness since 3 days ago. Slowly. History of head
injury (-).
 Cough since 1 month ago. Sputum (+) and white color. Bloody cough (-).
 History of night sweats without physical activity (+).
 Decreased of appatite (+) since 2 weeks ago.
 Decreased of bodyweight (+)
 Fever since 5 days ago. Intermittent. No chill and no exessive sweating.
 No nausea and vomite
 Shortness of breath since 2 days ago. Shortness of breath not affacted by
activity, weather and food. PND (-), DOE (-), OP (-).
 Micturation and defecation normal
 
Past Illness History
• History of HT (+) since 2 years ago. Routin controlled
• History of DM (-)

Family Illness History

• Nothing family with the same disease
 Physical Examination

 Consciousness level : Sopor

 BP : 90/70 mmHg

 HR : 114x/minute

 RR : 26x/minute

 T: 38,7 C
 Skin : Head : Turgor returns slowly

 Eye


 Conjunctiva are anemic -/-
 Sclera are icteric -/-

 Neck
 JVP 5-2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: fremitus : difficult to examine
 Percussion: dull
 Auscultation: Bronchovesicular, rales +/+ at upper of both lung, 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 palpabl and spleen no palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Oedem -/-
 Physiologic reflex +/+
 Pathologic reflex -/-
 Laboratory


Hb 14,5 gr/dl PH 7,46
Ht 43% PCO2 20
WBC 12.040/mm3 PO2 58
Platelet 379.000/mm3 HCO3- 14,2
Ur/Cr 253/3,5 BEecf -9,6
Na/K/Ca 157/3,2/8,5 SO2 91%
RBG 177 mg/dl
PT/aPTT 13,4/42,0


 Working Diagnosis

 Decreased of conciousness cb Hypernatremia cb
dehydration
 Septic shock cb bronchopneumonia (HCAP) with
respiratory failure type 1
 Acute on CKD

Dd/
 Decreased of conciousness cb Hypoxemia
 Decreased of conciousness cb Uremic
enchefalopathy
 Therapy

 Rest/Liquid diet 6x200 cc via NGT/ O2 NRM 10
L/1’
 IVFD NacL 0,45% 4 h/colf
 Inj. Meropenem 3x1 gr (IV)
 Drip Norephinefrin 1 amp in 50cc NacL 0,45%
(syring pump) start fast 10-15 mcg/kgBW/hour
 Paracetamol tab 3x500 mg (po)
 Nebu flumucyl/8 hour
 Positif fluid balance
 Planning

 Blood culture
 Sputum culture
 Kidney USG