CC: Chest pain since 3 days ago

Present illness History:

Chest pain since 3 days ago, 20 minutes, referred
to left arm
Epigastric pain since 3 days ago, no maag history
Hystory of hypertension 2 years ago, not control
Defecation & micturition normal
 GA:mild ,Consc:CMC ,BP: 150/90 mmhg ,Pulse:
110/m ,RR: 23/m ,T : 37 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: vesicular, ronki -/- ,wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC sin RIC VI
Percution : cardiomegali (+)
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Back: CVA pain -/-
Ext: physiologic reflect +/+, oedem +/+
Hb 17.4 g/dl
Ht 54 %
Leucocyte 15340/ul
Trombocyte 256.000/ul
Na/K/Ca 136/5.1/10.2
Ur/Cr 84/3.2
RBG 149 mg/dl
CK-MB 52 u/l
Trop I 0.47 ug/l
WD/: NSTEMI inferior
CHF Fc II LVH RVH RBBB incomplete rhythm cb HHD
AKI RIFLE F cb prerenal cb low cardiac output
Hypertension stg I cb essential
DD/: CHF Fc II LVH RVH RBBB incomplete rhythm cb CAD
Th/: Rest/Heart Diet II Low Salt II/02 3 lpm
IVFD NaCl 0,9% 12 hours/kolf
Drip NTG 1 amp in 50 cc NaCl 0.9% in syringe pump with
1.5 cc/hour
Loading aspilet 160 mg-> 1x 80 mg
Loading clopidogrel 300 mg-> 1x75 mg
Simvastatin 1x20 mg
Ramipril 1x 2.5 mg
Bisoprolol 1x2.5 mg
Catheter-Fluid Balance
 PT/aPTT
Echocardiography
Eye consult
 CC: Breathlessness increase since 1 day ago
Present Illness History:
-Breathlessness increase since 1 day ago, breathlessness
since 2 months ago, influenced by activity, no influenced by
season & food
Cough since 3 days ago, schlemm +, blood -
Fever since 3 days ago, high, no chill, no sweat. Now no
fever
Diarrhea since 1 day ago, frequency 7 times, gross, no
blood, no mucous
Micturition normal
 GA: mild, Consc: CMC, BP:130/70 mmhg
,Pulse: 100/m ,RR: 29/m ,T : 36,5 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation: bronchovesicular, rales +/+ , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin RIC V
Percution : cardiomegali (-)
Auscultation : heart sound irregular
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable, ballotement -
Percussion :tympani
Auscultation :bowel sound +
Back: CVA pain -/-
Ext: physiologic reflect +/+, oedem -/-
Hb 12.8 g/dl
Ht 40 %
Leucocyte 6000/ul
Trombocyte 141.000/ul
RBG 115 mg/dl
Ureum 30 mg/dl
Creatinine 0,8 mg/dl
pH 7,43
pCO2 34 mmHg
pO2 108 mmHg
HCO3- 22,6
Beecf -1,7
SO2 98%
Na/K 135/3,4
WD/: Bronchopneumonia duplex (CAP)
GEA type koleriform with hypocalemia
AF NVR cb electrolite imbalance
Th/: Rest/Low Fibre Diet/ O2 3lpm
IVFD RL 6 hours/kolf
Inj cefoperazone 2x1 g
Azithromicin 1x 500 mg
PCT 500 mg if needed
N asetil sistein 3x200 mg
KCL correction 20 meq in 200 cc Na Cl 0,9 % in 4 hours
Bisoprolol 1x5 mg
Ascardia 1x80 mg
Catheter-Fluid Balance
 Planning:
Sputum, feces culture
 CC: Breathlessness increase since 1 day ago
Present Illness History:
Breathlessness since 2 months ago, influence by
activity, not influence by weather & food
History of hypertension since 2 years ago, patient
control to doctor & get amlodipin 1x5 mg
Swollen of abdominal since 2 weeks ago
History of yellow disease denied
Tea like micturition denied. Defecation normal
 GA: mild,Consc: CMC,BP: 150/80 mmhg ,Pulse:
94/m ,RR: 26,T : 36,8 C
Eyes: anemic (+/+), icteric (-/-)
Chest: spider naevi -
Lung:
Inspection: simetric left=right
Palpation: right fremitus =left fremitus
Percussion: sonor
Auscultation: vesicular, ronchi -/-, wheezing -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger lat LMC sin
Percution : cardiomegaly +
Auscultation : rhytm reguler, heart sound normal
Abd:
Inspection : convex, collateral -
Palpation : liver & spleen unpalpable
Percussion : shifting dullness +
Auscultation :bowel sound +
Ext: physiologic reflect +/+, edema -/-, palmar
eritema +
Hb 8,7 g/dl
Ht 26 %
Leucocyte 5.400/uL
Trombocyte 90.000/uL
Alb/Glb 2,6/4,3
pH 7,44
pCO2 28 mmHg
pO2 96 mmHg
HCO3- 19 mmol/l
BEecf -5,2
SO2 98 %
WD/: - CHF Fc III LVH RVH sinus rhytm cb HHD
- Hypertension stg I cb essential
- Cirrhosis hepatis post necrotic decompensated
stage
- Mild anemia microcytic hypochrom cb chronic
disease
DD/ - Cirrhosis cardiac
Th/-Rest/Heart Diet II Liver Diet II/ O2 3 lpm
-Inj furosemid 1x 20 mg
-Ramipril 1x 5 mg
-Spironolacton 1 x 25 mg
-Curcuma 3 x 1 tab
-Catheter-Fluid balance
 Planning:
-MCV/MCH/MCHC
-SI, TIBC, Ferritin
-Lipid profile
-Hepatitis marker
-Abdominal USG
-Echocardiography
-Eye consult
 CC: black vomite since 1 days ago
Present Illness History:
-Black vomite since 1 day ago, vomite 3 times,
glass/day
-Black stool since 1 day ago, 4 times,
glass/times
-Pain on epigastric since 3 days ago, no reffered
pain
 GA:mild ,Consc:CMC ,BP:110/70 mmhg, Pulse:
92/m ,RR: 20/m ,T : 36.1 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion: sonor
Auscultation:vesicular, ronchi -/-, wh -/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 3 fingers under arc costae
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 10 g/dl
Ht 31%
Leucocyte 7200/uL
Trombocyte 64000/uL
SGOT 56 u/l
SGPT 33 u/l
Ureum 48 mg/dl
Creatinine 0.8 mg/dl
WD/: -Hematemesis melena cb gastropathy NSAID
-Hepatoma
Th/:
-Rest /NGT 8 hours-> Gastric diet I
-Prosogan 2 amp -> drip prosogan 2 amp in 500 cc NaCl 0.9%
12 hours/kolf
- Sucralfat 3xC 1
-Curcuma 3x1 tab
-Domperidone 3x10 mg
-Fluid balance-Cathether urine
 CC: Nausea since 6 hours ago
Present Illness History:
- Nausea since 6 hours ago, no vomit
- Previously headache 6 hours ago
- Previously pasien consume 10 eggs sleepy
drugs, 15 bodrex & baygon
- Patient look depression since 2 weeks ago.
- No breathlessness
 GA: severe,Consc: somnolen,BP:120/70 mmhg
,Pulse: 90/m ,RR: 22/m ,T : 37 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus=left fremitus
Percussion:sonor
Auscultation:vesicular, ronki-/- , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver & spleen unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
Hb 13,9 g/dl
Ht 42%
Leucocyte 10300/uL
Trombocyte 282000/uL
Na/K/Cl 140/3.3/105
RBG 109 mg/dl
Ureum 10 mg%
creat 0.8 mg%
WD/:-Bodrex intoxication
-Severe deprsion with temptamen
Th/: -Rest/Open NGT->fasting 8 hours
-IVFD EAS Pfrimmer: NaCl 0.9%= 1:1 500 cc/12 hours
-Meylon correction 200 meq in 200 cc NaCL 0.9%
-Inj lasix 2x1 amp Alinamin F 2x1 amp
-Ceftazidime 2x1 gram Ca.Gluconas 1 amp (extra)
-Levofloxacin 1x 200 mg PRC tranf post lasix
-Insulin bolus 10 unit in D 40% 2 fl slow inj
-Folic acid 1x10 mg
-Candesartan 1x8 mg
-Ambroxol 3x30 mg
 CC: Vomit since 4 days ago
Present Illness History:
-vomit since 4 days ago, frekuency >5 x/days, 1/2
glass /vomit, no bleeding. Patient had consumed
anti tuberculosis drug since 8 days ago
-cough since 3 months ago
- Fever since 1 month ago
- Decrease of body weight since 1 years ago
 GA: mild,Consc: cmc,BP:110/80 mmhg ,Pulse:
88/m ,RR: 22/m ,T : 37.6 C
Eyes: anemic (-/-), icteric (-/-)
Lung:
Inspection: simetric left=right
Palpation:right fremitus increasis > left fremitus
Percussion: dullness
Auscultation:bronchovesicular, rales +/+ , wh-/-
 Cor:
Inspection : ictus cordis not found
Palpation : ictus cordis 1 finger med LMC sin
Percution : heart size normal
Auscultation : heart sound normal
Abd:
Inspection :flat
Palpation : liver palpable 1 finger under arcus
costarum , blunt edge, flat, dullness & lien
unpalpable
Percussion :tympani
Auscultation :bowel sound +
Ext: physiologic reflect +/+
HB 11.4g/dl
HT 35%
Leucocyte 7700/uL
Trombocyte 578000/uL
Na/K/Cl 138/3.8/107
RBG 102 mg/dl
ureum 22
creatinin 0,6
WD/: Drug induced liver injury ec anti tuberculosis drug
Bilateral lung tuberculosis (in therapy)
Trombositosis reactive
dd/ dispepsia syndrome dismotility type
trombositosis essential
Th/: -Rest/liver diet II
-IVFD NaCl 0,9%:D5% 1:1 6 hours/kolf
-stop anti tuberculosis drug
-inj ondansetron 3 x 4 mg
-Curcuma 3 x 1 tab
- Ambroxol syr 3 x c1
 p/ ceck liver fungtion
Ceck marker hepatitis