Morning &

Duty
Report
30 September 2021 MORNING & DUTY REPORT
1

Assrianti Thalib/Female/46 YO/FW 17

Chief Complaint: Decreased of consciousness since 1 day ago

Present Illness History

• Decreased of consciousness since 1 day ago, it happen slowly, patient look
sleepy
• Looks pale since 1 week ago
• Fever since 5 days ago.
• Fatigue since 1 week ago.
• Nausea and vomiting since 5 days ago.
• Bloody urine since 1 day ago
• Patient has been know as Ca Cervix and had done Histerectomy at March
2021.
Past illness history

• History of hypertension is denied

• History of diabetes mellitus is denied

Family illness history

• No remarkable history
Physical Examination
VII

• General Appearance : Severe

• Consciousness level : Somnolen

• BP : 78/43 mmHg

• HR : 113 x/minute

• RR : 28 x/minute

• T : 38 ºC

• SaO2 : 98%
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• 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 6,5 gr/dl
Ht 18%
WBC 45.260/mm3
Platelet 9.000/mm3
Diff. Count 0/0/10/82/3/3
PT/APTT/D-dimer 11,9/32,2/470
Ur/Cr 274/4,7
SOGT/SGPT 25/14
Na/K/Cl 132/3,1/105
Alb/glo 2/2,5
Peripheral Blood Morphology
Chest X-Ray VII
ECG VII
Problems
• Decrease of conciousness
• Septic shock
• Hematuria
• Anemia
• Trombositopenia
• Leukositosis
• AKI
• hipoalbuminemia
Working Diagnosis
• Decreased of Consciousness cb Septic Associated Encephalopaty
• Septic Shock cb Urosepsis
• AKI Stage III cb Pre Renal cb Sepsis
• Hematuria
• Suggestive DIC
• Moderate Anemia cb Acute Bleeding
• Hypoalbuminemia
• Ca Cervix Post Histerectomy
Therapy
• Rest/liquid diet 4x200 cc via NGT
• IVFD NaCl 0,9%/6 hours
• Drip vascon 4mg in 50cc NaCl 0,9% from (0,05mcg) up titration
• Ceftriaxone 2x1gram IV
• Levofloxacin 1x750mg IV
• Transamin 3x500mg IV
• Vitamin K 3x10mg IV
• Paracetamol 3x500mg PO
• Albumin 25% Extra
• Folic acid 1x5mg PO
• Natrium bicarbonat 3x500mg PO
• Transfusi PRC 1 unit/ day
• Transfusi TC 10 unit
Plan
• Kidney USG
• Procalcitonin check