Duty Report

January 18th , 2017

Nurdeli, female, 72 yo, FW 03

 Cc:
◦ Decrease of consciousness since 3 days ago

 Present Illness History

◦ Decrease of consciousness since 3 days ago,
patient look sleepy
◦ Fever since 1 week ago
◦ Shortness of breath since 5 days ago
◦ Cough since 1 week ago
◦ Decrease of appetite (+)
 Defecation and micturition are normal
 Nausea and vomite (-)
 Bleeding (-)
 Looks pale increase since 1 week ago
 History of stroke 4 months ago
 History of digiti 1 pedis (d) amputation 4
months ago
 History of DM (+), usually got levemir 1x8 iu
and oral medication
 History of HT (+)
Physical Examination
 Consciousness level: somnolen

 BP : 160/70 mmHg

 HR : 100x/minute

 RR : 26 x/minute

 T: 38 C
 Eye
◦ Conjunctiva are anemic (+)
◦ Sclera are icteric (-)
 Neck
◦ JVP 5-2 cmH20

 Lung:
◦ Inspection: simetric at statis and dinamic
◦ Palpation: fremitus cannot be assessed
◦ Percussion: sonor
◦ Auscultation: vesicular, rales +/+, wet, soft and high pitch
wheezing -/-

 Cor:
◦ Inspection: ictus is unseen
◦ Palpation: ictus palpable 1 finger medial LMCS ICS V
◦ Percussion:
 Left border: ICTUS palpable 1 finger medial LMCS ICS V
 Right border: LSD
 Upper border: RIC II
◦ Auscultation: pure rhythm, no murmur
 Abdomen:
◦ Inspection: enlargement (-)
◦ Palpation: liver and spleen unpalpable
◦ Percussion: timpani
◦ Auscultation: bowel sound (+) normal

 Extremities:
◦ Physiologic Reflex +/+
◦ Pathologic Reflex -/-
◦ Oedema -/-
Laboratory Hb 7,6
HT 25%
WBC 22.900
Platelet 445.000
Ur/ cr 45/1,3
RBG 383
Na/K 129/3,0
pH 7,54
pCO2/pO2 40/123
HCO3-/BE 33,8/11,9
SaO2 99%
Keton urine ++
Urinalysis
Leu 6-8
Eritr 15-20
Protein ++
glucose +++
CHEST
X RAY
ECG
Working Diagnose
 Decrease of consciousness c.b Sepsis related
encephalopathy
 Sepsis c.b HCAP
 UTI
 Type 2 DM uncontrolled normoweight with
ketosis
 Old stroke
 Moderate anemia normositic normochrome c.b
chronic disease
 Hyponatremia and hypokalemia c.b low intake
 Stage I hypertension c.b essential
Differential Diagnoses
 Acute confusional state
 urosepsis
Therapy
 Rest/liquid diet 6x200 cc via NGT DD 1500 Kkal
low salt II/O2 2l/min
 IVFD NaCl 0,9% 12 hours/kolf
 Inj ceftazidime 2x1 gr
 Inf levofloxacin 1x750 mg
 Paracetamol 3x500 mg
 N acetyl sistein 3x200 mg
 Amlodipin 1x5 mg
 IVFD NaCl 3% 12 hrs/kolf (1 kolf)
 Correction KCL 25 meq in 200 cc NaCl 0,9% in 4
hrs
PRC transfusion
Foley cathether, fluid balance
Bolus insulin novorapid 5 IU
Drip insulin 50 IU in 48 cc NaCl 0,9%
(syringe pump) start with 2,5 cc/hrs
Check RBG /hrs
RBG > 250 : increase 0,5 IU
RBG < 250 : decrease 0,5 IU
Maintain RBG 140-180 gr/dl
Check K/6 hrs
Plan
 Sputum culture