Morning Duty Report

Liya Anjelina
1. Masita, female 64 YO. FW15
• Presenting complaint
unconciusness since 20 days ago

• History of presenting complaint

• unconsciousness since 20 days ago, preceded by paralysis of the right limb
• Fever since 4 days ago, no high, continuously
• No seizure
• breathlessness since 1 week ago, no cought
• Defecation and mixturation within normal limits

• Past medical history

• History of hypertension (+)
• History of diabetes (-)
• Drug history
• Patient consumed Antihypertension drug since 2 year ago but irregulerly

• Family history
• History of hypertension

• Social history 
• Patient was farmer
• Low economy
• general circumstances : severe
• level of consciousness : soporous
• TD : 140/90 mmHg
• RR : 22 x/s
• N : 105 x/s (regular)
• S : 37ºC
• Eye
• Conjunctiva anemic -/-
• Sclera icteric -/-

• Neck
• JVP 5+0 cmH20

• Lung:
• Inspection: simetric,
• Palpation: cant evaluated
• Percussion: sonor both of lung
• Auscultation: rales +/+, wheezing -/-
• Cor:
• Inspection: ictus wasn’t seen
• Palpation: ictus was palpated at 3 finger beside linea midclavicularis
• Percussion:
• Left border: 3 fingers lateral LMCS sinistra
• Right border: linea sternalis dextra
• Upper border: RIC II
• Auscultation: regular rhythm

• Abdomen:
• Inspection: enlargement (-), collateral vein (-)
• Palpation: hepar unpalpable
• Percussion: tympani
• Auscultation: bowel sound (+) N

• Extremities:
• Oedema -/-
 1. Masita , female 64 YO.
Diagnosis Hasil pemeriksaan yang telah dilakukan
• Decrease of conciusness ec Hb 10,3 g/dL AGD pH : 7,529 pCO2 : 39.2
sepsis related enchepalopathy Ht 33 % pO2 : 86.8 HCO3 : 32.6 mmol/L
• Sepsis ec Hospital acquired
pneumonia Leukosit 11.510 /mm3 BE : 10.1 mmol/L SO2 : 97%
• Stroke infarkd OH-19 Trombosit 256.000/mm3
• Hipertency stage I
DC 0/1/6/82/9/1
PT 11 detik
APTT 24 detik
INR 1,09
GDS mg/dL
Ureum 32 mg/dL
Kreratinin 0,7 mg/dL
LFG mL/mnt
Natrium 133 mmol/L
Kalium 4.6 mmol/L
Klorida 99 mmol/L
therapy Plan

Elevasi kepala 30º Sputume culture

NaCl 0,9% 12 hour/K Urinalyse
NRM 6 liter perminutes
Liquid diet low salt 1700
calories via NGT
Levofloxacin 1 x 750 mg
Azitromicyn 1 x 500 mg
Candesartan 1 x 16 mg
Simvastatin 1 x 20 mg
Omeprazole 2 x 20 mg
sukralfat 3 x 10 cc