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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