Duty Report

June 2th, 2021

 Animar 67 y.o, Female, HCU 04

Cc:
 Decreased of consciousness 12 hours ago.

• Present Illness History

 Decreased of consciousness 12 hours ago, suddenly, initially able
to communicate with, then suddenly unable to be awakened. Now
the patient is conscious
 Decrease of appetite since 1 week ago 1/4 portion of regular meal
 Breathlessness  increased since 2 days ago, affected by moderate
activity, not affected, weather and food. 
 Fever since 2 days ago, not high, no sweating , no shivering
 Cough since 2 days ago with white phlegm, no blood
 History of bleeding was denied
 Defecation and micturition was normal
• History of DM since 1 year ago. regular
consumption of metformin 2 x500 mg po,
glimepiride 1 x 2 mg po.
• History of HT (-)
 Physical Examination
• General appearance : Moderate
• Consciousness level : CMC
• BP : 120/70 mmHg
• HR : 68 x/min
• RR :  28 x/minute
• T :  37,9 oC
• Skin : ptechiae (-) purpura (-) ekimosis (-)
• Eye
• Conjunctiva anemic  (-)
• Sclera  icteric (-)

• Neck
• JVP 5-2 cmH20
• Lymph Node: Unpalpable
• Lung: 
• Inspection :  symmetric both of hemithorax
• Palpation : hard to examined
• Percussion :  sonor
• Auscultation : bronchovesicular, rales +/+, wheezing -/-
• Cor
• 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 : RIC II
• Auscultation: reguler, murmur (-)

• Abdomen:
• Inspection : enlargement (-)
• Palpation : hepar and lien unpalpable,
• Percussion : tympani,
• Auscultation : bowel sound (+) normal
• Flank : knocking and pressure pain at CVA -/-

• Extremities:
• Edema -/-,
• Physiologic Reflex +/+
• Pathologic Reflex -/-
 Laboratory
Hb 10,3 g/dl PT 10,3 s Ur 28 mg/dl pH 7,43
Leuko 7.660 /mm3 APTT 19,7 s Cr 1,3 mg/dl HCO3 27,5

Platelet 207.000 INR 0,93 Na 140 PCO2 40,6

/mm3 mmol/L
HT 31 D-Dimer 5137 K 4,2 mmol/ PO2 109
L
Diff 0/2/79/17/4 Cl 111 SO2 98
Count mmol/L

GDS 34178 BEef 2,8

mg/dl
Ro Thorax
 ECG
ECG INTERPRETATION

Irama Sinus P N

HR 80 PR <0,20

Axis N QRS <0,04

I,AVF
+/+ :N
+/-: LAD
-/+: RAD

R/S VI <1 ST Isoelectric

RVH

SV1+RV6 <35 T Tall -

LVH
 Working Diagnose
• Decreased of consciousness cb hypoglycemia
• Community acquired pneumonia
• Atherosclerosis heart disease
• OLD MCI
• Type II Diabetes Mellitus Overweight Uncontrolled
• Hypercoagulable state
 Differential Diagnose

• Decreased of consciousness cb Hemorrhagic stroke

 Therapy

• Rest/ Diet Diabetic 2200 kcal/O2 3 lpm

• IVFD D10% 6 hours/kolf
• Inj Ceftriaxon 2x1 gr iv
• Azithromycin 1 x 500 mg po
• N-acethylsistein 3x200 mg po
• Paracetamol 3x500 mg po
• Atorvastatin 1x40 mg po
 Plan

• Sputum culture
• Echocardiography