DUTY REPORT


October 8 , 2018
Joanas, female, 83nyo, MW 15
 Cc:
Vomite since 1 week ago

Present Illness History

- Vomite since 1 week ago. it contain of food
and water
- Nausea since 1 month ago
- Cough (+) phlegm (+) blood (-)
- Fever (+) chill (-)
- breathlessnes (-)
- micturation and defecation in normal limit
 
Past Illness History
•History of DM (-)
•History of HT (-)

Family Illness History

•No family have the same disease
Physical Examination

Consciousness level : CMC
BP : 100/60 mmHg

HR : 91x/minute

RR : 20x/minute

T: 37 C
 Eye

Conjunctiva are anemic -/-
Sclera are icteric -/-

Neck
JVP 5-2 cmH2o

Lung:
Inspection: simetric at statis and dinamic
Palpation: left = right fremitus
Percussion: sonor
Auscultation: bronkovesicular, rales +/+, wheezing( -)
• Cor:
– Inspection: ictus not seen
– Palpation: ictus is palpated at 1 finger
medial LMCS RIC V
– Percussion:
• Left border: 1 finger medial LMCS ICS
V
• Right border: linea sternalis dextra
• Upper border: RIC II
– Auscultation: pure rhythm, no murmur
  Abdomen:
Inspection: Enlargement (-)
Palpation: liver and spleen not palpable
Percussion: tympani
Auscultation: bowel sound (+) normal limit

Extremities:
Oedem -/-
Physiologic reflex +/+
Patologic reflex -/-
 Laboratory

Hb 11,1 gr/dl
Ht 35 %
WBC 8450/mm3
Platelet 253. 000/mm3
RBG 76 mg/dl
ur/ kr 40/0,8

Na/K/Cl 141/2,1/102

WBC 8450/mm3

total protein 5,2 g/dl

albumin /globulin 2,8/2,4 g/dl

 Working Diagnosis

Dyspepsia syndrom like ulcer type
BP (CAP)
Hypokalemia ec GI loss
Ves infrequent
 Therapy

Rest/ Gastric diet II
Drip KCL 35 meq in 200 cc NaCl 0,9
IVFD Nacl 0,9 % 8 hours/colf
inj. ceftriaxon 2x1 gr
Azitromisin 1x 500 mg
Domperidon 3x 10 mg
lansoprazole 1x 30 mg
N acetyl systein 3x200 mg