duty report thurrsday may 16th 2013
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8/13/2019 Duty Report Thurrsday May 16th 2013
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Cc: Swelling in chest increased since 3 months ago
Present Illness History: Swelling in chest increased since 3 months ago,size of eggs chicken,
swelling was felt since 1 year ago,initially at nut, pain (+) Swelling in the face since 3 months ago, arise suddenly,pain(-)
Breathlesness since 3 months ago, breathlesness increased if lie down anddecreased if take a seat Fever since 1week ago,not continuely,no sweat,no tremble, now no fever,
fever was felt 3 months ago Cough since 1 week ago,mucous (+),no bloody, cough was felt since 2
months ago Decrease of body weight since 1weeks
Apetite normal History of smoking since 27 years ago, 3 wrap /day History of get cancer drug (-) Vomit (-) 1 Year ago the patiens has been treatment in pulmonology department for
3 weeks
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Mixturation and defecation usuall
The patients sister suffer thyroid cancer and
had been operation 1997
Physical examination:
GA: Moderate
Consc: cmc
BP: 120/70 mmHg
Pulse: 80x/min
RR: 20x/min T: 36,5 C
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Eye: Conjunctiva anemis (-), Yellow greenishicteric (+)
Neck :Venectasi (+) JVP 5-2 cm H2OChest:Swelling size eggs chicken (7x5x1)cm,consistance
hard,surface flate,immobile,pain(+),pulsasion (-) Heart:normal Lung: Vesicular, Rhales (-)/(-) Abdomen
Liver and splen unpalpable Extrmities : RF (+)/(+) Normal,RP (-)/(-) NormalEdema (-)/(-)
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Lab: Hb: 10,9 gr% Leuco: 18.400/mm3 Ht: 35 % Trombo: 147.000/mm3
Na/K/Cl/Ca: 122/3,3/102 mmol/L Albumin : 2,3 Total Bilirubin : 17,81 Biliirubin direk : 16 Bilirubin Indirect : 1,81
SGOT : 235 SGPT : 98 PT :26,2 APTT :75,3
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WD: Tumors of Mediastinum
DD/ Bronchogenic Cancer
Lymphoma Malignum
Therapy Rest/ Daily Diet
Ambroxol Syr 3x CI
Tramadol 3x 1
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Planning- Ro thorak
- Citology sputum
- CT scan thorak- TTNA
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Critical Ill: Insulin 50 units dripped in 50 cc NaCl 0.9%
with syringe pump started from 1.5cc/h
Check RBG/h If RBG < 80: 0.5cc/h + D 40% 1 flacc
RBG 80-110: 1cc/h
RBG 110-160: 1.5cc/h
RBG 160-220: 2cc/h RBG > 220: 2.5cc/h + insulin bolus 8u IV
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Check K/6h If K < 3.5: KCl correction 40 meq
K 3.5-4.5: 20 meq
K 4.5-5.5: 10 meq K > 5.5: -
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Ambroxol syr 3xcth2 PCT 3x500mg
Amlodipine 1x5mg
Candesartan 1x8mg Folic acid 1x5mg
Bicnat 3x500mg
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Physical examination: GA: moderate
Consc: CMC
BP: 110/60 mmHg Pulse: 96x/min
RR: 23x/min
T: 37.7 C
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Eye; anemic conj +/+, icteric sclera -/- Heart: cardiomegali -, murmur -
Lung: bronchovesiculer, rales +/+, wh -/-
Stomach: distension +, liver and spleen werehard to measure, shifting dullness +
Extr: edema +/+, erythema of palmar +/+,flapping tremor -
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Lab: Hb: 6.3 gr% Leuco: 5000/mm3 Ht: 19 % Trombo: /mm3 PT:16.2 APTT: 44.2 D-Dimer: 1.5 Alb/glob: 2.4/2.1
SGOT/SGPT: 21/21 Bil I/II: 0.87/0.91 HBsAg -
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Thy: Rest/flowing NGT fasting max 3 days hepar diet I IVFD Aminofusin:triofusin:NaCl 0.9% 1:2:1 8 h/kolf Stilamin 1 amp dripped in 50 cc NaCl 0.9%, bolus 4cc then
continue drip with syringe pump 4.1cc/h IVFD NaCl 3% 12h/kolf
Ceftriaxone vial 1x2gr Transamin amp 3x1 Vit K amp 3x1 Curcuma 3x1 Sistenol 3x1 KSR 1x1 Ambroxol syr 3xcth2 Cross match PRC tranfusion until Hb > 8gr% Klisma twice a day
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Cc: pro 4thchemotherapy indicated by nonHodgkin limfoma malignant oculi dextra
Present Illness History:
Pro 4thchemotherapy indicated by nonhodgkin limfoma malignant oculi dextra
Fever
Cough
Decrease of appetite -
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Physical Examination: GA: moderate
Consc: CMC
BP: 120/70 mmHg Pulse: 88x/min
RR: 20x/min
T: 36.7 C
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Eye: anemic conj -/-, icteric sclera /- Pulmo: vesiculer, rh -/-, wh -/-
Cor: cardiomegali -, murmur -
Abd: liver and spleen were unpalpable Extr: edema -/-
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Lab: Hb: 11.5 gr%
Leuco: 3700/mm3
Ht: 31 % Trombo: 5000/mm3
Na/K/Cl: 135/4.3/107 mg%
RBG: 106 mg%
Ur/Creat: 17/1 mg%
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WD: Pro 4thchemotherapy indicated by non
hodgkin limfoma malignant oculi dextra
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Therapy: Rest/soft diet high calories high protein
IVFD NaCl 0.9% 8h/kolf
PCT 500mg 3x1 NTR 2x1
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Cc: diarrhea since 5 days agoPresent illness history:
Diarrhea since 5 days ago
Abdominal pain since 5 days ago Thirst (+), weak (+)
Decrease of appetite since 5 days ago
Nausea +
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Physical Examination: Vital sign : GA : moderate; blood pressure
110/70; pulse 90x; T: 36.7 ; RR : 22x
Eyes :anemic conj -/-, icteric sclera -/-
Lung: vesiculer, rales -/-, wh -/-
Heart: cardiomegali -, murmur
Stomach: liver and spleen were unpalpable
Daldiyono score: 1
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Lab: Hb: 16.7 gr%
Leuco: 8400/mm3
Trombo: 251000/mm3 Ht: 48%
Na/K/Cl: 138/3.9/105 mmol/L
RBG: 88 mg%
Ur/creat: 24/1.1 mg%
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WD: Acute gastroenteritis colliform type without
dehydration
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Thy: Rest/soft diet low fiber
IVFD NaCl 0.9% 8h/kolf
PCT when needed NTR 2x1
Oralit when needed
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Cc: fever since 2 weeks ago
Present Illness History:
Fever since 2 weeks ago Headache since 2 weeks ago
Nausea since 2 weeks ago
Fatigue since 2 weeks ago
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Physical examination: GA: moderate
Consc: CMC
BP: 130/70 Pulse: 110x
RR: 22x
T: 38 C
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Eye: anemic conj -/-, icteric sclera -/- Lung: vesiculer, rh -/-, wh -/-
Heart: cardiomegali -, murmur
Stomach: liver and spleen were unpalpable Extr: edema -/-
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Lab: Hb: 12.4 gr% Ht: 39% Leuco: 10700/mm3 Trombo: 178000/mm3 Na/K/Cl: 129/3.2/95 mmol/L RBG: 115mg% Ur/creat: 20/1 mg% S. tyhphii H: 1/80 S. thyphii O: 1/80
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Wd: Susp Malaria
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Thy: Rest/daily diet
IVFD RL 6h/kolf
PCT 3x500mg NTR 2x1
Domperidone 10mg 3x1
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Cc: increase of breathlessness since 2 daysago
Present illness history:
Increase of breathlessness since 2 days ago
Cough since 3 months ago
Mixturation frequence decreased since 3
months ago Diabetic history since 15 yrs ago
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Physical examination: Consc: CMC
GA: moderate
BP: 160/100 Pulse: 82x
RR: 24x
T: 36.2 C
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Eye: anemic conjunct +/+ Lung: bronchovesiculer, rales +/+
Ext: edema +/+
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WD/ Stage V CKD cb nephropathy DM with
metabolic acidosis
BP duplex (CAP) with type I respiratory failure
Type II DM controlled by diet normoweight +necrotic digiti I pedis dextra
Pulmonary TB
Bilateral pleural effusion cb specificDD/ cb hypoalbuminemia
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Thy: Rest/soft diet DD 1700 kkal low salt II low protein 40
gr/NRM 10 L/1 IVFD Easpfrimmer 500 cc/24h Lasix amp 1x1 Ceftriaxone vial 1x2gr Folic acid 1x5mg Amlodipine 5mg 1x1 Candesartan 8mg 1x1 Ambroxol syr 3xcth2 Cross match PRC tranfusion post lasix until Hb > 10gr% Meylon correction 150 mg in 150 cc naCl 0.9% fast drip
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Cc; epigastric pain since 1 week ago
Present illness history:
Epigastric pain since 1 week ago
Cough since 1 week ago
Fever since 3 days ago
Hypertension history since 1 month ago
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Physical examination Consc: CMC
GA: moderate
BP: 160/80pulse; 80x
RR: 21x
T: 36.8
Lung: bronchovesiculer, rales +/+
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Lab: Hb: 10.2
Leuco: 13600
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WD/ Gastropathy NSAID DD/ gastric ulcer
CAP Geriatric
Stage II Hypertension cb essensial
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Thy: Rest/low salt II gastric diet II/O2 5 L/1 IVFD D5% 8h/kolf Ceftriaxone vial 1x2gr Azythromicine 1x500mg Ozid amp 1x1 Sucralfat syr 3xcth2 Ambroxol syr 3xcth2 Amlodipine 1x5mg Candesartan 1x8mg
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