Duty Report

April 8th, 2021

 Darmansyah, 45y.o, male, HCU12
• Cc:
 Decreased of consciousness since 2 days ago.

• Present Illness History

 Decreased of consciousness since 2 days ago. initially the patient can be
invited to communicate, slowly the patient is a lot sleepy
 Fatique since 1 week ago
 Breathlessness Increased since 2 days ago. , was not affected by activity,
weather and food.
 Fever since 2 days ago continuously ,sweating (-) shivering (-)
 Cough since 2 days ago with white phlegm (+) bloody(-)
 Nausea (-), vomit (-)
 History of bleeding: Gum bleeding (-) Skin bleeding/ bluish on the skin (-),
nosebleed(-) black defecation before( -) black vomit before (-)
 Defecation and Micturition was was normal
• History of HT (-)
• History of DM (-)
 Physical Examination
• Consciousness level: Somnolence
• BP : 110/60 mmHg

• HR : 97 x/min

• RR : 22x/minute

• T: 37oC
• Skin : ptechiae (-) pupura (-) ekimosis (-)
• Eye
• Conjunctiva anemic (+)
• Sclera icteric (-)

• Neck
• JVP 5-2 cmH20

Lymph Node: unpapble

• Lung:
• Inspection: symetric left=right
• Palpation: fremitus left=right
• Percussion: sonor
• Auscultation: bronchovesicular, rales +/+ wheezing -/-
COR
• Abdomen:
• Inspection: enlargement (-)
• Palpation: Hepar and spleen unpalpable, shifting
dullness (-)
• Percussion: tympani
• Auscultation: bowel sound (+) normal
• Flank : knocking and pressure pain at CVA -/-
• Extremities:
• Edema -/-
• Physiologic Reflex +/+
• Pathologic Reflex -/-
 Laboratory
Hb 8,9 g/dl Ur 61 mg/dl Albumin 2,2 g/dl pH 7,46
Leukocyte 6.380/mm3 Cr 1,6 mg/dl Globulin 4,3 g/dl PCO2 30,4

Platelet 125.000/mm3 Na 123 mmol/L SGOT 60 u/L PO2 29,8

HT 27 K 2,4 mmol/L SGPT 32 U/L SO2 63,7

Diff 0/0/78/8/4 Cl 97 mmol/L PT 10,7 s HCO 22,3

Count 3
Ca 8,9 APTT 30,6 s BEecf -1,8

RBG 115 mg/dl D- 5284 INR 1,01

dimer
Ro Thorax
 Working Diagnose
• Decreased of consciousness ec Hyponatremia
• Hospital Aquired Pneumonia with type 1 respiratory failure
• Hyponatremia ec SIADH
• Hypokalemia ec Gitelman Syndrome
• Hypoalbuminemia ec Renal Loss
• AKI Stage I ec pre renal ec dehydration
• Mild Anemia ec Normocytic Normochrome ec Occult bleeding
• Hypercoagulable State
 Differential Diagnose
• Decreased of consciousness ec Hypoxemia
• Hyponatremia ec Renal Loss
• Hypokalemia ec Bartter Syndrome
• Hypoalbuminemia ec Low Intake
• AKI Stage I ec post renal ec obstruction
• Mild Anemia ec Normocytic Normochrome ec Chronic Disease
 Therapy
• Rest/ Soft Diet / NRM O2 10 L/i
• IVFD NaCl 3% 500 cc/12 hours
• Inj Cefepime 3 x 1 gr iv
• Inj Levofloxacin 1 x 750 mg iv
• Drip KCl 25 mEq in 200 cc NaCl 0,9% /4 hours
• Albumin Tranfusion 20% 100 cc extra iv
• N-Acethylsistein 3x200 mg po
• Paracetamol 3x500 mg po
• KSR 3x600 mg po
• Fluid balance
Plan
• Urinary electrolytes
• Kidney Ultrasound
• Sputum culture