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8/12/2019 Duty Report 20 Dec
1/19
JANUARY 3 th 2014
8/12/2019 Duty Report 20 Dec
2/19
CC : Epigastric pain increase since 3 days ago
Present illness history: Epigastric pain increase since 3 days ago, especialy
midnight
History of maag since 5 years ago, uncontrolled and never
to endoscopy Fever since 1 weeks ago,no High, intermitten, no
shivering, no sweat
Breathlessness (-)
Cough to day , no sputum, no blood Nausea (+) since 3 days ago and vomite to day, frequent :
2-3 x/days, consist what ate, volume -1/2 glass, no blood
Decrease of appetite (+) since 1 weeks ago
Defecate and urinate usual
8/12/2019 Duty Report 20 Dec
3/19
Consc : fully alert
BP : 120 /80 mmHg
HR : 88 x/
RR : 20 x/
T : 37 0 CEye : Conjuctiva anemic (-),sclera icterus (-)
Neck : JVP 5-2 mmHg
Lung : Brochovesiculer, rales (+/+) wet, Whezzing (-/-)
Heart : ictus was palpable 1 finger medial of LMCS RIC V
Abdomen: Liver and spleen unpalpable, epigastric pain (+)
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal Edem (-)/(-)
8/12/2019 Duty Report 20 Dec
4/19
Hb : 12,7 gr/dl
Leu : 11.700/mm3
Ht : 36 %
Trombosit : 276.000 /mm3Na : 132 mmol/L
K : 3,4 mmol/L
RBG : 105 mg/dL
Ureum : 13 mg/dLCreatinin : 0,8 mg/dl
8/12/2019 Duty Report 20 Dec
5/19
WD/:
Dyspepsia like ulcer type
Community acqueried Pneumonia (CAP)
8/12/2019 Duty Report 20 Dec
6/19
Rest/ Gastric diet II
IVFD NaCl 0,9 % 8 hrs/kolf
Prosogan inj 1 x 1 vial (IV)
Ceftriaxon inj 1 x 2 gr ( ST )Sukralfat syr 3 x cth 1
Domperidon 10 mg (if needed)
PCT 500 mg ( if needed)
8/12/2019 Duty Report 20 Dec
7/19
Lung X-ray
Gastroscopy
Culture sputum
8/12/2019 Duty Report 20 Dec
8/19
CC : Breathlessness increase since 1 days ago
Present illness history: Breathlessness increase since 1 weeks ago. Its felt since
2 days ago, increase with activity and no influence weather
and food
Breathlessnes felt on sleep History of wake up midnight cause by short breath
Cough since 3 months ago, white sputum, no blood
Headache since 1 days ago
History HT since 1 years ago, uncontrolled, and no drinkdrugs
Fever (-)
Urinate unsatisfy and not fluent since 3 months ago.
Urinate stone exit and sand (-)
8/12/2019 Duty Report 20 Dec
9/19
Consc : fully alert
BP : 210/90 mmHg
HR : 96 x/
RR : 32 x/
T : 37 0 CEye : Conjuctiva anemic (+),sclera icterus (-)
Neck : JVP 5+0 mmHg, massa size 1,5x2x2 cm,soft,mobile
Lung : Bronchovesiculer, rales (+/+) wet, Whezzing (-/-)
Heart : ictus was palpable 1 finger lateral of LMCS RIC VI,reguler rythm, Murmur (-)
Abdomen: Liver and spleen unpalpable
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal Edem (-)/(-)
8/12/2019 Duty Report 20 Dec
10/19
Hb : 8,2 gr/dl
Leu : 11.700 /mm3
Ht : 24 %
Platelet : 391.000 /mm3Sodium : 137 mmol/L
Potasium : 3,5 mmol/L
Ureum : 189 mg/dL
Creatinin : 12,4 mg/dLCCT : 4,46
8/12/2019 Duty Report 20 Dec
11/19
WD/:
CKD stage V CbCHF fc. II LVH RVH sinus rythm Cb ASHD
Community acquired pneumonia
8/12/2019 Duty Report 20 Dec
12/19
Rest/ Low protein diet 50 gr/ Low salt II/Heart diet II/ O2 3l/1 IVFD NaCl 0,9 % 12 hrs/kolf
Ceftriaxone inj. 2 x 1 gr ( skin test )
Lasix inj. 1 x 1 amp
Azitromycin 1 x 500 mg
Candesartan 1 x 8 mg
Ambroxol syr. 3 x cth 2
Curcuma 3 x tab 1Apply Folley catheter - Fluid Balance
8/12/2019 Duty Report 20 Dec
13/19
Lung X-ray and BNO Exp.
Sputum culture
8/12/2019 Duty Report 20 Dec
14/19
CC : Fever since 2 days before admission
Present illness history: Fever since 2 days before admission , high, continue,
intermitten with shivering and no sweat
Cough since 4 months ago, Brethlessness (-)
Previously last 5 day of patient suffer diarrhoea, frequent 5x/day, Vol. 1 glass/diarrhea
Nausea (+) and vomite (-)
Pain of Both genue since 1 months ago
History of rheumatic drugs from healthcare (+) waist pain since 1 weeks ago, repaired pain to stomach
intermitten
Urinate usual and Pain (+)
Defecate wateryly 1 this day, frequent 1 x
8/12/2019 Duty Report 20 Dec
15/19
Consc : fully alert
BP : 130 /80 mmHg
HR : 112 x/
RR : 32 x/
T : 39,5 0 CEye : Conjuctiva anemic (+),sclera icterus (-)
Neck : JVP 5-2 mmHg
Lung : BronchoVesiculer, rales (+/+) , Whezzing (-/-)
Heart : ictus was palpable 1 finger medial of LMCS RIC V,
reguler rythm, Murmur (-)
Abdomen: Liver and spleen unpalpable
Ext : Fisiology reflex :(+)/(+) Normal
Pathology reflex:(-)/(-) Normal Edem (-)/(-)
8/12/2019 Duty Report 20 Dec
16/19
Hb : 7,8 gr/dl
Leu : 2.200/mm3
Ht : 32 %
Platelet : 165.000 /mm3RBG : 117 mg/dL
Na : 139 mmol/L
K : 4 mmol/L
Ureum : 31 mg/dLCreatinin : 1,1 mg/dL
8/12/2019 Duty Report 20 Dec
17/19
WD/:
Sepsis Cb BPBilateral lung tuberculosis
Moderate anemic microcytic hypocrome Cb
Chronic disease
8/12/2019 Duty Report 20 Dec
18/19
Rest/ Soft diet / O2 2 L/1
IVFD NaCl 0,9 % 6 hrs/kolf
Ceftriaxone inj. 1 x 2 gr ( skin test )
Ciprofloxacin inf. 2 x 200 mg (iv)Continue OAT drugs
PCT 3 x 500 mg(if necessary)
Ambroxol syr. 3 x 1 cth
Fluid Balance
8/12/2019 Duty Report 20 Dec
19/19
Lung X-ray Exp.
Culture sputum