CC: Decrease of conciousness since 1 day ago

Present Illness History:

Decrease of conciousness since 1 days ago
History of right waits pain since 6 months ago
History of pain when micturition +, no bleeding
History of DM, hypertension denied
Defecation normal
 GA:severe ,Consc:Sopor ,BP: 100/60 mmhg
,Pulse: 97/m ,RR: 28/m ,T : 37 C
Eyes: anemic (+/+), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:fremitus cant assess
Percussion:sonor
Auscultation: vesicular, ronki -/- ,wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin RIC V
Percution : cardiomegali (-)
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable, ballotement -
Percussion :tympani
Auscultation :bowel sound +
Back: CVA pain cant assess
Ext: physiologic reflect +/+, oedem -/-
Hb 9,9 g/dl
Ht 27 %
Leucocyte 5560/ul
Trombocyte 133.000/ul
RBG 125 mg/dl
Ureum 323 mg/dl
Creatinine 4,7 mg/dl
pH 7,24
pCO2 28 mmHg
pO2 45 mmHg
HCO3- 12
Beecf -15,4
SO2 71%
Na/K 134/2,4
Proteinuria ++
CKD-EPI 11 cc/mnt
WD/: Decrease of conciousness cb uremic encephalopahty
Acute on CKD cb nephropathy obstruction cb nephrolitiasis
dextra with metabolic acidosis
Mild anemia microcytic hypochrom cb chronic disease
Hypokalemia
Th/: Rest/NGT Fluid Diet 6x150cc Low protein 48 gr/ O2 10
lpm via NRM
IVFD EAS Primmer 500 cc/24 hours
Meylon correction 200 meq in 200 cc NaCl 0.9% in rapid
KCL correction 25 meq in 200 cc NaCl 0,9 % in 4 hours
Bicnat 3 x500 mg
Folic acid 1x5 mg
Catheter-Fluid Balance
 MCV/MCH/MCHC
SI, TIBC, Ferritin
Renal USG
Urology consult
 COMPREHENSIVE GERIATRIC
ASSESSMENT

Penapisan Depresi : sukar dinilai

MMSE : sukar dinilai
ADL Barthel : 2 (ketergantungan total)
Uji Mental Singkat : sukar dinilai
MNA : 18 (berisiko malnutrisi)
 CC: Breathlessness increase since 1 week ago
Present Illness History:
-Breathlessness since 10 days ago
Cough since 7 days ago, schlemm +
History of pain on joint since 3 months ago
Photofobia since 3 months ago
Rash on face since 1 months ago
Defecation normal
 GA: mild, Consc: CMC, BP:90/50 mmhg ,Pulse:
110/m ,RR: 48/m ,T : 40,3 C
Eyes: anemic (+/+), icteric (-/-), malar rash +
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: bronchovesicular, rales +/+ , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin RIC V
Percution : cardiomegali (-)
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, oedem -/-
Hb 7.1 g/dl
Ht 23 %
Leucocyte 3.370/ul
Trombocyte 279.000/ul
MCV 89 fL
MCH 28 pg
MCHC 31 %

Proteinuria +
WD/: Septic shock cb bronchopneumonia duplex (CAP)
SLE
Bicytopenia cb SLE
Nefritis Lupus
Th/: Rest/Low protein 48 gr/02 5 lpm
Rehidration with NaCl 0,9 % until sistolic pressure >= 100
mmHg/ UO >= 1 cc/KgBB/hour
Drip 1 amp vascon in 50 cc NaCl 0,9 % in syringe pump in
0,37 cc/hour
Inj Ceftriaxone 1x2 g
Inf levofloxacin 1x500 mg
Paracetamol 3x500 mg
Nebu farbivent/8 hours
Catheter-fluid balance
 Planning:
Reticulocyte
ANA Test
Sputum culture
 CC: Breathlessness increase since 1 day ago
Present Illness History:
Breathlessness since 1 month ago. Breathlessness
influence by activity, not influence by weather &
food
Nausea & vomite since 5 days ago. Vomite 6-7
times/day. Vomite glass/ vomite
Chest pain
Micturition & defecation normal
 GA: mild,Consc: CMC,BP: 100/70 mmhg ,Pulse:
86/m ,RR: 29,T : 36,7 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation: right fremitus =left fremitus
Percussion: sonor
Auscultation: vesicular, ronchi -/-, wheezing -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC sin ICS VI
Percution : cardiomegaly +
Auscultation : rhytm irreguler, heart sound normal
Abd:
Inspection : flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+, edema -/-
Hb 12,4 g/dl
Ht 33 %
Leucocyte 12.300/uL
Trombocyte 355.000/uL
RBG 174 mg/dl
Ur/Cr 30/0,8
pH 7,38
pCO2 32 mmHg
pO2 29 mmHg
HCO3- 18,9
BEecf -6,2
SO2 54%
WD/: - CHF Fc III LVH RVH sinus rhytm cb ASHD
- Gastropathy NSAID
- Hyponatremia cb vomite
Th/-Rest/Heart Diet II Gastric Diet II/ O2 10 lpm via
NRM
-IVFD NaCl 3% 12 hours/kolf (3 kolf)
-Inj Lansoprazole 1x30 mg
-Sucralfat 3xC 1
-Domperidone 3x10 mg
-Ramipril1x 2.5 mg
-Spironolacton 1x25 mg
-Inj. Furosemid 1x20 mg
-Catheter-Fluid balance
 Planning:
-Echocardiography
-Esofagogastroduodenoscopy
 CC: black vomite since 1 days ago
Present Illness History:
-Black vomite since 1 day ago, vomite 3 times,
glass/day
-Black stool since 1 day ago, 4 times,
glass/times
-Pain on epigastric since 3 days ago, no reffered
pain
 GA:mild ,Consc:CMC ,BP:110/70 mmhg, Pulse:
92/m ,RR: 20/m ,T : 36.1 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion: sonor
Auscultation:vesicular, ronchi -/-, wh -/-
 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 3 fingers under arc costae
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 10 g/dl
Ht 31%
Leucocyte 7200/uL
Trombocyte 64000/uL
SGOT 56 u/l
SGPT 33 u/l
Ureum 48 mg/dl
Creatinine 0.8 mg/dl
WD/: -Hematemesis melena cb gastropathy NSAID
-Hepatoma
Th/:
-Rest /NGT 8 hours-> Gastric diet I
-Prosogan 2 amp -> drip prosogan 2 amp in 500 cc NaCl 0.9%
12 hours/kolf
- Sucralfat 3xC 1
-Curcuma 3x1 tab
-Domperidone 3x10 mg
-Fluid balance-Cathether urine
 CC: Nausea since 6 hours ago
Present Illness History:
- Nausea since 6 hours ago, no vomit
- Previously headache 6 hours ago
- Previously pasien consume 10 eggs sleepy
drugs, 15 bodrex & baygon
- Patient look depression since 2 weeks ago.
- No breathlessness
 GA: severe,Consc: somnolen,BP:120/70 mmhg
,Pulse: 90/m ,RR: 22/m ,T : 37 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation:vesicular, ronki-/- , wh-/-
 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 & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 13,9 g/dl
Ht 42%
Leucocyte 10300/uL
Trombocyte 282000/uL
Na/K/Cl 140/3.3/105
RBG 109 mg/dl
Ureum 10 mg%
creat 0.8 mg%
WD/:-Bodrex intoxication
-Severe deprsion with temptamen
Th/: -Rest/Open NGT->fasting 8 hours
-IVFD EAS Pfrimmer: NaCl 0.9%= 1:1 500 cc/12 hours
-Meylon correction 200 meq in 200 cc NaCL 0.9%
-Inj lasix 2x1 amp Alinamin F 2x1 amp
-Ceftazidime 2x1 gram Ca.Gluconas 1 amp (extra)
-Levofloxacin 1x 200 mg PRC tranf post lasix
-Insulin bolus 10 unit in D 40% 2 fl slow inj
-Folic acid 1x10 mg
-Candesartan 1x8 mg
-Ambroxol 3x30 mg
 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
 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 +/+ , wh-/-
 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 +
Ext: physiologic reflect +/+
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