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Chief
complaint
decrease of consciousness since 2 day
ago
Present illness history
decrease of consciousness from 2 days ago, going
slowly. Previous patients can still communicate.
Fever since 1 weeks ago, continuously, not high, no
chills, and not sweating a lot
Cough since 1 weeks ago, with phlegm, blood (-)
Shortness of breath since 2 days ago, do not shrink,
not influenced activity, weather and food.
Decreased appetite (+) since 2 weeks ago
Naussea and vomit since 2 weeks ago, containing
food
Hystory of diabetes meliitus since 3 years ago and
routine controlled
Patient had been hospitalized at RS Ibnu Sina 2
Physical Examination
BP : 130 / 70 mmHg
HR : 112 x/minute
RR : 26 x/minute
T: 37,6 C
Eye
Conjunctiva anemic +/+
Sclera icteric -/-
Neck
JVP 5 - 2 cmH20
Lung:
Inspection: simetris sinistra = dextra
Palpation: fremitus sinistra = dextra
Percussion : sonor
Auscultation: Broncovesiculer, Rh +/+, wh -/-
Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger medial LMCS ICS V
Percussion:
Left border: 1 finger medial LMCS ICS V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: pure rhythm, murmur (-)
Abdomen:
Inspection: enlargement (-)
Palpation: hepar and spleen not palpable
Percusion : tympani
Auscultation: bowel sound (+) normal
Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Laboratory
Keterangan Nilai
Hb 9,8
Leukosit 16.030
Ht
Trombosit .000
GDR 216
Ur / Cr /
Na / K /
Ph 7,18
Pc02 71
Po2 60
Hco3- 26,5
Beecf -1,9
so2 83
06/11/2017
Working Diagnose
Decrease of consciousness cb
hyponatremia
Hyponatremia cb vomit
Type 2 DM uncontrolled
bronchopneumonia dupleks (HCAP)
with respiratoty failure type I
Lung TB
Mild anemia normocytic normochrom cb
chronic disease
Hypokalemia
Therapy
rest /liquid diet DD 1900 Kkal by NGT/O2 NRM 10 lt / i
IVFD Nacl 0.9 % 12 hours/kolf ( 2 kolf )
Ceftriaxone 1x2 gr
Levofloxacin 1x 500 mg
Paracetamol 3x 500 mg
N. Acetil sistein 3x 200 mg
Lansoprazole 1x 30 mg
Fluid balance