Duty report

Jan 29 th, 2018

Ernita A , female, 64 yo, HCU A

Chiefcomplain
Chest pain since 1 days ago
 Present illness history
◦ Chest pain since 1 days ago. Feel like uncomfort in
chest. But now this symtompt has gone.
◦ Shortness of breath since 3 days ago. not influenced
by activity, weather and food. Sleep with elevated
pillow (-)
◦ Black stool since 1 day ago.
◦ Fever since 1 week ago, not high not chill
◦ Cough since 1 week ago, with sputum
◦ Urination was normal
◦ Naussea and vomit (-)
◦ Hystory of hypertension since 4 years ago and get
amlodipi, candesartan and DM since 2 years ago and

12/03/2018
 Patient had been know suffer colitis with
mioma uteri and cholelithiasis and kidney
disease

12/03/2018
Physical Examination
 level of consciousness : CMC

 BP : 80 / 40 mmHg

 HR : 114 x/minute

 RR : 22 x/minute

 T: 36,9 oC
 Eye
◦ Conjunctiva are anemic -/-
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation: bronchovesicular, Rh +/+at basal, Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medall LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur (-)
 Abdomen:
◦Inspection: Enlargement (-)
◦Palpation: liver and spleen not palpable
◦Percussion: tympani
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema -/-
Laboratory
Examination Result
Hb 11 g/dl
Leukosit 16250 / mm3
Trombosit 209.000 / mm3
Ur / Cr 37/3
GDS 87
Na / K / Cl/Ca 138/2,4/114/4,5
Hematokrit 29 %
Ph 7,433
Pco2 18,2
Po2 206,1
Hco3- 12,3
Beecf
so2 99,6

12/03/2018
Working Diagnose
 NSTEMI
 Septic shock cb bronchopneumonia
(HCAP)
 Hematemesis melena cb stress ulcer
 Type 2 DM uncontrolled.
 UTI
 Mioma uteri
 Cholelithiasis
 Hypocalsemia et hypokalemia
Therapy
 rest / liquid diet 6x200cc gastric diet I DD 1500 kkal / 02 3 L/i
 Loading nacl 0,9 % 200 cc until BP 100 mmhg
 Bolus prosogan 80 mg  drip prosogan 80 mg in 500 cc nacl 0,9 %
in 8 hr
 Meropenem 3x 1 gr
 Paracetamol 3x500 mg
 Nebu flumucyl/8 hr
 Sucralfat syr 3x cth 11
 Salofalk 3x 500 mg
 Drip ca gluconas 3 amp in 100 cc in 1 hr
 Drip Kcl 40 meq in 200 cc Nacl 0,9 % in 4 hr
 Fluid balance