Beruflich Dokumente
Kultur Dokumente
dr. Rangga
Suhayati, Female, 61yo, HCU02
Cc:
Decreased of conciousness since 4 hours ago
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