CC: Decrease of conciousness since 4

days ago

Present Illness History:
Decrease of conciousness since 4 days
ago
History of hypertension(-)



GA:moderate Consc:sopor BP:100/60
Pulse: 96x/m RR 23x/m T: 38,1 C
Eyes: anemic (-), icteric (-)
Lung: Rales +/+
Cor: normal
Abd: normal
Hb: g/dl
Leu: /mm3
Ht: %
Tromb: /mm3
Na/K/Cl: //
RBG:
Ur/Cr: / mg/dl
HbsAg: (-)
Rapid test: ()


WD/:
Decrease of conciousness cb hipoglikemia sequele
Sepsis cb CAP
DM tipe 2 uncontrollable normoweight
CKD stg IV cb nephropathy DM with Acidosis
Metabolic

Th/:
- Rest/NGT MC Free 24 hour/DD 1700 Kkal
- IVFD D 10%/8 hour/kolf
- Inj.Ceftriaxone 1x2 gr iv skin test
- Ciprofloxacin 2x200
- PCT 3x1
- Foley Catheter
- Hipoglikemia Protocol

CC:Breathlessness since 15 days ago
Present Illness History:
Breathlessness since 15 days
ago,increase with activity
Enlargement abdomen since 2 month
ago
Has been known suffer DM since 2
years ago
GA:moderate Consc:cmc BP:180/90
Pulse: 87x/m RR 40x/m T: 37 C
Eyes: anemic +/+
Neck:JVP 5+2 cmH2O
Lung: normal
Cor: ictus was palpabled 1 finger lat
LMCS RIC VI
Abd: Hepar palpabled 2 finger
BAC,dull,flat,solid
Hb: 7,3 g/dl
Leu: 11000/mm3
Ht: 23%
Tromb: 266.000/mm3
Na/K/Cl: 127/6.8/109
RBG: 136
Ur/Cr: 138/10,2

WD/:
CKD stg V cb nephropaty DM with Acidosis Metabolic
CHF fc III LVH RVH sinus rhytm cb HHD DD/ASHD
DM tipe 2 controllable with diet normoweight
Th/:
- Rest/DD 1700 Low salt II Low protein 40 gr/O2 2L/i
- IVFD Easpfrimmer 500 cc/24h
- Lasix inj 2x1 amp
- Ceftriaxone 1x2 gr/iv
- Amlodipin 1x5 mg
- Candesartan 1x8 mg
- Bicnat 3x500 mg
- Folat acid 1x5 mg
- Inj Ca gluconas 1 amp
- Kalitake 3x1
- Foley CathFluid Balance

Correction of Meylon 150 meq into 150 cc Nacl 0,9%
rapid drip
PRC transfusion until Hb reach or same with 10
CC:
Present Illness History:

GA:moderate Consc:cmc BP:110/70 Pulse:
80x/m RR 24x/m
T: 36,3 oC
Eyes: anemic +/+
Pulmo: normal
Cor: normal
Abd: normal
Extr: oedem -/-

Hb: 7.7 g/dl
Leu: 12400/mm3
Ht: 25%
Tromb: 384.000/mm3
Na/K/Cl: 134/4.7/108
Ur/cr: 50/0.9



WD/:
Hematemesis e.c Gastropathy NSAID
Moderate anemia normositic normochrom cb acute
bleeding

Th/:
Rest/ flow NGT 8 hour continue with Gaster diet
IVFD NaCl 0.9% 8 hour/kolf
Ceftriaxon 1x2 gr IV
Sucralfat syr 3xc1
Ciprofloxacin 2x500 mg
Transamin inj 3x1
Vit K inj 3x1
Foley catheter
Transfussion PRC until Hb reach or same with 10


CC: Breathlessness since 15 days ago

Present Ilness History:
Breathlessness since 15 days ago,influence by activity
GA: moderate Consc:CMC BP:140/90
Pulse: 78x/m RR 26x/m T: 36,7oC
Eyes: anemic (-),icteric(-)
Lung: bronchovesiculer, Rh +/+, Wh -/-
Cor: normal
Abdomen : hepar was palpabled 2 fingers
UAC, dull, flat surface,



Hb: 4,9 g/dl
Leu: 12.000/mm3
Ht: 15%
Na/K/Cl:121/3,8/97
RBG: 99 mg/dl
Alb/glob: 2/2,2
Bil I/II: 0,48/1,19
SGOT/SGPT: 45/26
Ur/cr: 38/1 mg/dl


WD/:
CPC std decompensata
CAP
DM tipe 2 uncontrollable normoweight
AKI Rifle I e.c prerenal e.c dehydration
Th/:
Rest/ DD 1900 Kkal/02 3L/Low salt II
IVFD NaCl 0.9% 12 hour/kolf
Ceftriaxone 1x2 gr iv
Azitromicin 1x500 mg
Spironolactone 1x25
Ambroxol syr 3xc1
PCT 3x500
Novorapid 3x8 iu
Amlodipin 1x5 mg
Fluid balancefoley cath

CC: breathlessness since 2 day ago

Present illness history:
Breathlessness (+),influenced by activity
Has been known hypertension since 5 yeras
ago
Cough(+)since 7 days ago
Fever (+) since 7 days ago, not high


GA:moderate Consc:cmc BP:170/110
Pulse: 104x/m RR 32x/m T: 36,8 oC
Eyes: anemic (-), icteric (-)
Lung: broncovesiculer, rales +/+, Wh -
/-
Cor: Ictus palpable 1 finger lateral
LMCS RIC VI
Abdomen:Hepar palpabled 2 finger
BAC,dull,flat surface



Lab:
Hb: 10.1 g/dl
Leu: 14900/mm3
Ht: 30%
Tromb: 319000/mm3
Na/K/Cl:132/4.2/97
Ur/cr: 86/4.7





WD/:
CKD stg V cb nephrosclerosis hypertension with acidosis
metabolic
Hipoglikemia e.c low intake
CHF FC III LVH RVH sinus rhtyhm tachicardia e.c ASHD
BP Duplex with hipoxia
Th/:
Rest/DD 1700 ccal
IVFD D 10% 12 hour/kolf
Protocol Hypoglikemia
Correction meylon 200 meq into 200 cc Nacl 0.9% in
rapid drip
Lasix inj 1x1 amp
Ceftriaxone inj 1x2 gr/iv
Amlodipin 1x5 mg
Candesartan 1x8 mg
CC: Breathlessness since 2 days ago

Present illness history:
Breathlessness since 2 days
ago,influenced by activity
Fever since 7 days ago

GA:moderate Consc:cmc BP:100/60
Pulse: 92x/m BR 36x/m T: 37,2oC
Eyes: anemic (+), icteric (-)
Ear:blood(+),pus(+)
Pulmo: broncovesiculer,rales +/+
Cor: normal
Abdomen:Hepar palpable 2 finger
BAC,dull,solid,flat surface
Extr: oedem -/-




Lab:
Hb: 9.9g/dl
Leu: 15200/mm3
Ht: 31%
Tromb: 249.000/mm3
Na/K/Cl:132/4,4/105
ur/cr: 17/1 mg/dl




WD/:
CHF FC IV LVH RVH sinus rhythm normorespon cb ASHD
CAP
OMA AS std perforata
Mild anemia normositic normochrome cb chronic disease

Th/:
Rest/Heart diet II/O2 3L/i
IVFD D5% 12 hour/kolf
Ceftriaxone inj 1x2 gr/iv
Lasix inj 1x1 amp
Cardase 1x2.5
Tyarit 2x200 mg
Alprazolam 1x0,5 mg
Dulcolax 1x2 tab
Ambroxol syr 3xc1
Foley cathether-fluid balanced


CC: decrease of conciousness since 3
days ago
Present Illness History:
Decrease of conciousness since 3 days
ago
Cough(+) since 7 days ago
Fever(+) since 7 days ago
GA:moderate Consc:somnolen
BP:100/60 Pulse: 80x/m RR 24x/m T:
36,8 oC
Eyes: anemic (+), icteric (-)
Pulmo:broncovesiculer,rales +/+
Cor:normal
Abd:normal





Lab:
Hb: 7,8 g/dl
Leu: 57.000/mm3
Ht: 24%
Tromb: 189000/mm3
RGB: 79
Ur/cr:115/3.7




WD/:
Syok Sepsis cb CAP
AKI Rifle F e.c prerenal e.c dehydration
Moderate anemia normositic normochrome cb
chronic disease
Th/
Rest/Soft diet/O2 3L/i
IVFD Nacl 0.9% guyur until BP 100 mmHg or
urine output 0,5 cc/kgBB continue with IVFD
Nacl 0.9% 8 hour/kolf



Ceftriaxone inj 1x2 gr/iv
Ciprofloxacin 2x200 mg
Ambroxol 3xc1
PCT 3xr500 mg
Fluid balanceFoley cath
Deksametason inj 3x1 amp
Correction of meylon 100 meq into 100 cc Nacl 0.9 %
rapid drip
CC: decrease of conciousness since 2
days ago
Present Illness History:
Decrease of conciousness since 3 days
ago
Cough(+) since 6 days ago
Fever(+) since 5 days ago
Decrease of weight(+)
GA:moderate Consc:somnolen
BP:110/60 Pulse: 74x/m RR 29x/m T:
36,7 oC
Eyes: anemic (-), icteric (-)
Pulmo:broncovesiculer,rales +/+
Cor:normal
Abd:normal





Lab:
Hb: 15,7 g/dl
Leu: 7.900/mm3
Ht: 48%
Tromb: 33000/mm3





WD/:
Syok Sepsis cb CAP
AKI Rifle F e
Th/
Rest/Soft diet/O2 3L/i
IVFD Nacl 0.9% guyur until BP 100 mmHg or
urine output 0,5 cc/kgBB continue with IVFD
Nacl 0.9% 8 hour/kolf