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    Duty Report: June 2th, 2021

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    Sarah
    - Monitor closely, provide supportive care and antibiotics for pneumonia - Further evaluate diabetes and cardiovascular status with recommended tests - Consider discharge pending clinical improvement and test results

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    Duty Report: June 2th, 2021

    Uploaded by

    Sarah
    21 views12 pages
    - Monitor closely, provide supportive care and antibiotics for pneumonia - Further evaluate diabetes and cardiovascular status with recommended tests - Consider discharge pending clinical improvement and test results

    Original Title

    Animar HCU4

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    - Monitor closely, provide supportive care and antibiotics for pneumonia - Further evaluate diabetes and cardiovascular status with recommended tests - Consider discharge pending clinical improvement and test results

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    21 views12 pages

    Duty Report: June 2th, 2021

    Uploaded by

    Sarah
    - Monitor closely, provide supportive care and antibiotics for pneumonia - Further evaluate diabetes and cardiovascular status with recommended tests - Consider discharge pending clinical improvement and test results

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 12

    Duty Report

    June 2th, 2021


    Animar 67 y.o, Female, HCU 04

    Cc:
     Breathlessness  increased since 2 days ago
    • Present Illness History
     Breathlessness  increased since 2 days ago, affected by moderate
    activity, not affected, weather and food. 
     Fever since 2 days ago, not high, no sweating , no shivering
     Cough since 2 days ago with white phlegm, no blood
     History of loss of consciousness 12 hours ago, suddenly, initially
    able to communicate with, then suddenly unable to be awakened.
    Now the patient is conscious after being given a D40% bolus in
    the ED
     Decrease of appetite since 1 week ago 1/4 portion of regular meal
     History of bleeding was denied
     Defecation and micturition was normal
    • History of DM since 1 year ago. regular
    consumption of metformin 2 x500 mg po,
    glimepiride 1 x 2 mg po.
    • History of HT (-)
    Physical Examination
    • General appearance : Moderate
    • Consciousness level : CMC
    • BP : 120/70 mmHg
    • HR : 72 x/min
    • RR :  28 x/minute
    • T :  37,9 oC
    • Skin : ptechiae (-) purpura (-) ekimosis (-)
    • Eye
    • Conjunctiva anemic  (-)
    • Sclera  icteric (-)

    • Neck
    • JVP 5-2 cmH20
    • Lymph Node: Unpalpable
    • Lung: 
    • Inspection :  symmetric both of hemithorax
    • Palpation : hard to examined
    • Percussion :  sonor
    • Auscultation : bronchovesicular, rales +/+, wheezing -/-
    • Cor
    • Inspection : ictus is not seen.
    • Palpation : ictus is palpated at 1 finger lateral LMCS ICS VI
    • Percussion:
    • Left border : 1 finger Lateral LMCS ICS VI
    • Right border : linea sternalis dextra
    • Upper border : RIC II
    • Auscultation: reguler, murmur (-)

    • Abdomen:
    • Inspection : enlargement (-)
    • Palpation : hepar and lien unpalpable,
    • Percussion : tympani,
    • Auscultation : bowel sound (+) normal
    • Flank : knocking and pressure pain at CVA -/-

    • Extremities:
    • Edema -/-,
    • Physiologic Reflex +/+
    • Pathologic Reflex -/-
    Laboratory
    Hb 10,3 g/dl PT 10,3 s Ur 28 mg/dl pH 7,43
    Leuko 7.660 /mm3 APTT 19,7 s Cr 1,3 mg/dl HCO3 27,5

    Platelet 207.000 INR 0,93 Na 140 PCO2 40,6


    /mm3 mmol/L
    HT 31 D-Dimer 5137 K 4,2 mmol/ PO2 109
    L
    Diff 0/2/79/17/4 Cl 111 SO2 98
    Count mmol/L

    GDS 34178 BEef 2,8


    mg/dl
    Ro Thorax

    • Besar dan bentuk dalam batas normal, CTR < 50%.


    Jantung & Aorta • Apex berada dikiri.
    • Aorta tidak elongatio.

    Trakea • berada di tengah

    • Hilus kanan dan kiri normal.


    Paru • Corakan bronkovaskuler kedua paru normal.

    Diafragma • berbentuk kubah kanan lebih tinggi dari kiri

    Sudut • lancip
    costroprenicus
    Tulang tulang • intact

    Soft tissue • dalam batas normal

    Kesan : 
    • Pemeriksaan foto toraks saat ini dalam batas
    normal.
    ECG ECG INTERPRETATION

    Irama Sinus P N

    HR 78 PR <0,16

    Axis LAD QRS <0,04


    I,AVF
    +/+ :N
    +/-: LAD
    -/+: RAD

    R/S VI <1 ST Isoelectric


    RVH

    SV1+RV6 <35 T V1,v5


    LVH Inverte I,AVL
    d
    Working Diagnose

    • Community acquired pneumonia (Geriatrics)


    • Post hypoglycemia
    • Type II Diabetes Mellitus Overweight Uncontrolled
    • Atherosclerosis heart disease
    • Old MCI Anterolateral
    • Hypercoagulable state
    Therapy

    • Rest/ Diet Diabetic 1500 kcal/O2 3 lpm


    • IVFD D10% 6 hours/kolf
    • Inj Ceftriaxon 2x1 gr iv
    • Azithromycin 1 x 500 mg po
    • N-acethylsistein 3x200 mg po
    • Paracetamol 3x500 mg po
    • Atorvastatin 1x40 mg po
    Plan

    • FBG, OGTT, HbA1c Test


    • Lipid Profile Test
    • Sputum culture
    • Echocardiography

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