Morning &

Duty
Report
30 September 2021 MORNING & DUTY REPORT
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

1
Hosri yelvi /Male/69 yo/ FW 21
Chief Complaint:

• Decreased of consciousness since 2 days ago

Present Illness History

• Decreased of consciousness since 2 days ago, it happened slowly, then

patient difficult to communicate to others.
• Breathlessness increased since 2 days ago, has been felt since 1 week
ago.no affected by activity, food , and weather.
• Fever since 3 day ago, high, no chilling and no excessive sweating.
• Cough since 1 week ago, sputum (+) , blood (-).
• Urination, volume and frequency is normally
• Defecation was normal
• History of DM since 1 year ago
• History of hypertension(-)
Past illness history

• Pulmonary TB (-)
• Kidney stone (-)

Family illness history

• No family the same with apatient

Physical Examination
VII

• General Appearance : Severe

• Consciousness level: somnolen

• BP : 90/50 mmHg

• HR : 130 x/minute

• RR : 29 x/minute (Kussmaul)

• T : 37,5 º C

• SaO2 : 94 %
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus can’t be ratedd
– Percussion: sonor
– Auscultation: broncovesicular, Rh +/+ Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger lateral LMCS ICS VI
– Percussion:
• Left border: 1 finger lateral LMCS ICS VI
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (+)
– Palpation: hepar and spleen is not palpable
– Percussion: tympani,
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 9,7 gr/dl
Ht 29 %
WBC 35170 /mm3
Platelet 528.000/mm3
Diff. Count 0/0/95/3/

RBG 767
Ur/Cr 66/1,5
SOGT/SGPT 15/10
Na/K/Cl/Ca 132/5,5/104/10,5
Alb/glo 3,8/3,6

BGA 7,25/16,8/74,8/7,6/-20.4/92.7%
Chest X-Ray VII
ECG VII
Problems

• Decreased of consciousness
• Breathlessness
• Acute Kidney Injury
• Hyperkalemia
• Hyperglicemia
Working Diagnosis

• Decreased of consciousness cb Septic Related Encephalopaty

• Sepsis ec Hospitality Acquired Pneumonia
• Hospitality Acquired Pneumonia with respiratory failure stag1
• Acute kidney injuri stage 1 pre renal cb sepsis
• DMT2 uncontrolled underweight
• Hyperkalemia
• Mild anemia normositic normokrom cb chronic disease
Differential Diagnosis

• Decreased of consciousness cb Sepsis Associated

Encephalopathy
• DKA
Therapy

• Rest/ Diet DD 2100 kkal via NGT

• O2 via NRM 10 lpm
• IVFD NaCl 0,9 % 6 cc/24 hour
• Drip insulin critical ill
• Inj. Cefepim 3 x 2 gr IV
• Inf. Levofloxacin 1 x 750 mg IV -> 1X 250 mg IV
• Kalitake 3 x 1 sacc Po
• Paracetamol 3 x 500 mg Po
• N-acetylsistein 3 x 200 mg Po
Plan

• Sputum culture
• Blood culture