1.

Erman Tanjung, male, 56 yo

CC: Breathlessness increase since 1 day ago
Present Illness History:
- Breathlessness increase since 1 day ago.
Breathlessness since 1 month ago, influence
by activity, not influence by season, weather
Cough since 6 month ago, white schlemm, no
blood, patient diagnose TB, get OAT 5 months
Chest pain -
Defecation normal & micturition orange
Physical Examination

GA: moderate, Consc: CMC,

BP:150/90 mmhg ,Pulse: 78/m ,RR:
28/m ,T : 37 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation: stem fremitus left=right
Percussion:sonor
Auscultation: bronchovesicular, rales +/+ ,
wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC
sin RIC VI
Percution : cardiomegali (+)
Auscultation : regular rhtym, heart sound
normal
Abd:
Inspection : convex
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: pathologic reflect -/-, oedem +/+
Lab Hb 12,6 g/dl
Ht 38%
Leucocyte 5.410/ul
Trombocyte 262.000/ul
RBG 128 mg/dl
Ureum 25 mg/dl
Creatinine 0,9 mg/dl
Na/K 143/3
pH 7,43
pCO2 34 mmHg
pO2 128 mmHg
HCO3- 22,6 mmol/l
BEecf -1,7 mmol/l
SO2 99 %
WD/: CHF Fc III LVH RVH sinus rhytm cb CAD
Lung Tuberculosis duplex on therapy
Ischemic Miocard Lateral
Th/: Rest/Heart Diet II Low Salt II/02 5 lpm
IVFD NaCl 0,9 % 12 hours/kolf
Drip lasix 5 amp in 50 cc NaCl 0,9% in syringe
pump in 2,5 cc/hours
Ramipril 1x 5 mg
Spironolacton 1 x 25 mg
Nebu fluimucyl/8 hours
Paracetamol 500 mg (if needed)
Rifampisin 1 x 450 mg
INH 1 x 300 mg
Vit B6 1x1 tab
Ascardia 1 x 80 mg
Simvastatin 1 x 20 mg
Catheter-fluid balance
 Planning:
Echocardiography
BTA
2. Zuherman Bahar, male, 68
yo
CC: Decrease of conscioussness since 1
day ago
Present Illness History:
Decrease of conscioussness since 1 day ago
Hystory of DM since 1 years ago,
comsumption glibenclamid 1x 5 mg
Nausea since 1 month ago, vomite
Hystory of chest pain
Micturition & defecation normal
Physical Examination

GA: Mild,Consc: Somnolen,BP: 120/80

mmhg ,Pulse: 84/m ,RR: 21,T : 36,8 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation: fremitus left=right
Percussion: sonor
Auscultation: vesicular, ronchi -/-,
wheezing -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC
sin ICS V
Percution : cardiomegaly -
Auscultation : rhytm reguler, heart sound
normal
Abd:
Inspection : flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: oedema -/-
Lab
Hb 8,7 g/dl
Ht 25 %
Leucocyte 7.090/uL
Trombocyte 271.000/uL
RBG 22 mg/dl
Ur/Cr 70/5,2
Na/K/Ca/Cl 136/4,4/8,2/106
WD/: - Decrease of conscioussness cb
hypoglicemia
- CKD stg V cb nephropathy DM
- DM type 2 uncontroled normoweight
- Mild anemia normochitic
normochrom cb CKD
Th/: Rest/NGT-> Free Diet-> DD 1700 kcal Low
Protein 48 gr/02 5 lpm
IVFD D 10 % 8 hours/kolf
Check RBG/15 minutes, if
RBG<60 mg/dl: D 40% 2 fl
RBG 60-80 mg/dl: D 40% 1 fl
-If RBG 3x >100 mg/dl, check RBG/hours
-If RBG 3x>100 mg/dl, check RBG/4 hours
-If RBG 100-200 mg/dl->IVFD D5% 8 hours/kolf
-If RBG >200 mg/dl->IVFD NaCl 0,9% 8
hours/kolf
-Bicnat 3 x 500 mg
- Folic acid 1 x 5 mg
-Catheter-fluid balance
 Planning:
-Renal USG
-Fasting Glucose, Post Prandial Glucose, HbA1c,
Profil Lipid
3. M Solihin, male, 67 yo
CC: Breathlessness increase since 1
days ago
Present Illness History:
-Breathlessness since 2 weeks ago,
influence by activity, not influence by
weather & food
-Hystory of DM since 1 year ago,
consumption glibenclamid 1 x 5 mg
-Micturition & defecation normal
Physical Examination

GA:mild ,Consc:somnolen ,BP:130/80

mmhg, Pulse: 92/m ,RR: 28/m ,T :
36.6 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:fremitus left=right
Percussion: sonor
Auscultation:bronchovesicular, ronchi +/
+, wh -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC
sin ICS VI
Percution : cardiomegaly (+)
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen palpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedema +/+
Lab
Hb 12,2 g/dl
Ht 36%
Leucocyte 7240/uL
Trombocyte 120.000/uL
RBG 242 mg/dl
Na/K 135/3.2
Ureum 31 mg/dl
Creatinine 1.1 mg/dl
pH 7,43
pCO2 38 mmHg
pO2 113 mmHg
BEecf 0,9 mmol/l
HCO3- 25.2 mmol/l
SO2 99 %
WD/: -CHF Fc III LVH RVH sinus rhytm cb ASHD
-DM type 2 diet uncontrolled overweight
Th/:
-Rest /Heart Diet II DD 1700 kcal/02 3 lpm
-IVFD NaCl 0.9% 12 hours/kolf
-Drip lasix 5 amp in 50 cc NaCl 0,9 % in syringe
pump in 2,5 cc/hour
-Spironolacton 1 x 25 mg
-Candesartan 1x 4 mg
-Inj Novorapid 3 x 8 u, Check RBG before meal:
If RBG < 200 mg/dl: -
If RBG 200-300 mg/dl: + 3 u
If RBG >300 mg/dl: + 5u
-Fluid balance-Cathether urine
 Planning:
-Echocardiography
-Fasting BG/Post Prandial BG
-HbA1c, Profil Lipid
5. Basri, male, 62 yo
CC: Breathlessness increase since 1 day ago
Present Illness History:
- Breathlessness since 2 weeks ago, influence
by activity
-Hystory of smoker since 10 years old
-Hystory of hypertension since 1 year ago,
comsumption captopril 3 x 12,5 mg
-Cough since 1 month ago, no blood
-Hystory of night sweat denied
-Micturition & defecation normal
Physical Examination

GA: moderate,Consc: CMC,BP:160/90

mmhg ,Pulse:98/m ,RR: 30/m ,T : 37,6
C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric right<left
Palpation:right fremitus<left fremitus
Percussion:dull ICS IV dextra
Auscultation:right: breath sound decrease
left:bronchovesicular, ronki+/+ , wh+/+
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC
sin ICS VI
Percution : cardiomegaly (+)
Auscultation : heart sound normal
Abd:
Inspection :convex
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedema +/+
Lab
Hb 14,8 g/dl
Ht 44 %
Leucocyte 16.670/uL
Trombocyte 320.000/uL
Alb/Glb 3,8/2,6
RBG 104 mg/dl
Ureum 33 mg/dl
Creatinine 1 mg/dl
pH 7.37
pCO2 47 mmHg
pO2 114 mmHg
HCO3- 27.2 mmol/l
BEecf 1.9 mmol/l
SO2 98 %
WD/:-CPC stg decompensata
-COPD on acute exacerbation
-Pleural effusion dextra cb malignancy
-Hypertension stg II essential
Th/: -Rest/Low Salt II/O2 3 lpm
-IVFD NaCl 0.9% 12 hours/kolf
-Drip lasix 5 amp in 100 cc NaCl 0,9 % in
microdrip in 5 tpm
-Nebu farbivent/8 hours
-Nebu fluimucyl/8 hours
-Candesartan 1x 8 mg
-Inj. Cefriaxone 1x 2 g
-Amlodipin 1 x 5 mg
-Spironolacton 1 x 25 mg
-Azithromycin 1 x 500 mg
-Paracetamol 3x500 mg
-Inj metil prednisolon 2 x 62,5 mg
-Catheter-Fluid balance
 Planning:
-Spirometri
-Pleural effusion analyze
-Sputum culture
-Eye consult
7. Novalinda piliang, female,
44 yo,FW 11 (seri amni
siregar)
CC: Vomit since 4 days ago
Present Illness History:
-vomit since 4 days ago, frekuency >5
x/days, 1/2 glass /vomit, no bleeding.
Patient had consumed anti tuberculosis
drug since 8 days ago
-cough since 3 months ago
- Fever since 1 month ago
- Decrease of body weight since 1 years ago
Physical Examination

GA: mild,Consc: cmc,BP:110/80

mmhg ,Pulse: 88/m ,RR: 22/m ,T :
37.6 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus increasis > left
fremitus
Percussion: dullness
Auscultation:bronchovesicular, rales +/
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC
sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 1 finger under
arcus costarum , blunt edge, flat, dullness
& lien unpalpable
Percussion :tympani
Auscultation :bowel sound +

Lab
HB 11.4g/dl
HT 35%
Leucocyte 7700/uL
Trombocyte 578000/uL
Na/K/Cl 138/3.8/107
RBG 102 mg/dl
ureum 22
creatinin 0,6
WD/: Drug induced liver injury ec anti
tuberculosis drug
Bilateral lung tuberculosis (in therapy)
Trombositosis reactive
dd/ dispepsia syndrome dismotility type
trombositosis essential
Th/: -Rest/liver diet II
-IVFD NaCl 0,9%:D5% 1:1 6 hours/kolf
-stop anti tuberculosis drug
-inj ondansetron 3 x 4 mg
-Curcuma 3 x 1 tab
- Ambroxol syr 3 x c1
 p/ ceck liver fungtion
Ceck marker hepatitis