1

Asma/ Female/ 72 YO/ HCU

Chief complain : Decrease of consciousness since 1 day ago

Present illness history :

•Decrease of consciousness since 1 day ago, Initially the patient was still able to
communicate, then did not respond
•Shortness of breath since 3 days ago, shortness of breath not affected by activity,
weather, or food
•Cough since 3 days ago, bloody sputum (-)
•Fever since 1 days ago, no chills, no sweating
•history of lying down since 1 month ago
•No wounds on the buttocks and waist
•There is nausea, no vomit
•Mixturition and defecation was normal
•There is no history of bleeding
Physical Examination
VII

• General Appearance : severe

• Consciousness level: sopor

• BP : 158/90 mmHg

• HR : 62 x/minute

• RR : 38 x/minute

• T : 38,6º C
• SpO2 : 99%
• Eye VII
– conjunctiva anemic (-)
– Icteric sclera (-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: Broncovesicular, Rh +/+, Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS VI
– Percussion:
• Left border: 1 finger medial 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 12 gr/dl
Ht 36 %
WBC 17.050 /mm3
Platelet 190.000 /mm3
Diff. Count 0/0/89/7/4
PT/APTT/d dimer 11,3/26,8/> 10.000
RBG 370
Ur/Cr 41/0,8
SOGT/SGPT 12/6
Na/K/Cl 144/3,8/112
Alb/glo 2,6/3,2
pH/pCO2/pO2/HCO3 7.46/20/157/14,2/-8,4/99%
Chest X-Ray VII
ECG VII
Problem VII
• Decrease of consciousness
• Hyperglycemia
• Hypoalbuminemia
Working Diagnosis

• Decrease of consciousness cb sepsis acquired

enchepalopaty
• Sepsis cb CAP
• Tipe II diabetes mellitus uncontrolled normoweight
• Hypertension stage 1
• Hypoalbuminemia
• High risk VTE
• Immobilization with total dependence
Therapy

• Rest/ liquid meal Diabetic Diet 4 x 200 ml via NGT

• IVFD Nacl 0,9 % 8 hours/kolf
• Drip insulin criticall ill
• Ceftriaxone 2 x 1 gram iv
• Levofloxacine 1 x 750 mg iv
• Asetil sistein 3 x 200 mg po
• Parasetamol 3 x 500 mg po
• Candesartan 1 x 8 mg po
Plan

• Urinalysis