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YASMITA-PPDS IPD
She complained about nausea since 4 days ago, sometimes followed with vomit, bloating sensation, and made her loss of appetite, even more she couldnt ate anything in the last 4 days. Px also suffered from blurred vision since 5 years ago, in left eye couldnt saw anything. had a history of DM since 10 years ago, ever consumed glibenclamide, but didnt took medicine since 6 months ago. Family history: mother and father had DM
PHYSICAL EXAMINATION
BP =140/80 mmHg PR = 100 bpm, reguler RR =24 tpm Tax : 37,4C
General appearance looked moderately ill Head Neck Thorax: Cor: Anemic +/+ JVP R + 5 cmH2O 30 Invisible and palpable at 2cm lateral ICS V MCL Sinistra RHM SL Dextra LHM ictus S1 S2 single Simetric, SF D = S, bv bv bv bv bv bv Rh + + ++ ++ Wh - --GCS 456; looks overweight Icteric -/-
Lung:
Abdomen Extermities
Soufle, BS (+) Liver span 10cm, traubes space thympani Icteric-, edema -
(Normal) 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L < 200 mg/dl 3,5-5,5 g/dl 10-50 mg/dL 0,7-1,5 mg/dL
SGOT
SGPT
99
48
11-41U/L
10-41U/L
eGFR
23.5
ml/mnt/1.73 m2
URINALYSIS
Lab SG PH Leucocyte Nitrite Protein
1.030 5.5 3+ 3+ 1+
Value
Lab 10 x
Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 40 x Erythrocyte
Value
+ -
Glucose
Erythrocyte Keton urine Urobilinogen Bilirubin
2-3
1-2 +
1+ -
BGA
Temp PH PCO2 PO2 HCO3 O2 sat Art BE True o2 37.4 C 7.51 23.1 147.0 18.6 99.3 - 4.6 85.7 O2 7.35-7.45 35 45 mmHg 80 100 mmHg 21 28 m mol/L > 95 % (-3) - (+3) m mol/L
CXR
CXR 27/05/2012
AP position, asymmetric, enough KV, enough inspiration Trachea in the middle Soft tissue and bone normal Phrenico costalis angle dextra and sinistra are sharp Hemidiaphragma dextra and sinistra are dome shape Lung: infiltrat and air bronchogram at both of lung, consolidation in upper and middle right lung. Cor : CTR : 68%. Conclusion : cardiomegaly, pneumonia
ECG
ECG
Sinus rhytm, Heart rate 100 bpm Frontal Axis : Normal Horisontal Axis : Normal PR interval : 0,12 QRS complex : 0,09 QT interval : 0,36 Conclusion : sinus rhytm HR 100 bpm
PL
IDx
PDx
PTx
PMo
Female/65 yo Generalized weakness Shortness of breath Nausea vomitting History of DM since 10 years ago, never took medicine in the last 6 months PE: BP. 140/80 PR.100 RR. 24 Lab: RBS 589109 pH 7.42 HCO3 18.4 Osmolarity 294.8 Anion gap 15.97 UL: glucose 3+ keton 1+
O2 2-4 Lpm via NC Rehydration 2-3L of NS 0,9% over first 1-3h Actrapid 10iu (iv) Line I:drip actrapid 50iu in 250mL NS 0,9% 25 mikrodrip/mnt5iu/h Line II:drip KCl 30mEq in 500mL NS 0,9% 10 dpm Until RBG<250 Line I:drip actrapid 50iu in 250mL D51/2NS 12 mikrodrip/mnt2,5iu/h Line II:drip KCl 30mEq in 500mL NS 0,9% 10 dpm Until RBG<200 Giving subcutaneous insulin: *Insulatard 0-10iu *Actrapid 4iu-4iu-4iu Stop insulin and KCl drip after 2 hoursNS 0,9% Lifeline
Subjecti ve BP HR RR BW SE
PL
Idx
PDx
PTx
PMo
Female/ 65 yo History of DM since 10 years ago, never took medicine in the last 6 months Lab: RBS 589109 Female/65 yo Cough 4 days, without sputum Low grade fever Shortness of breath PE: BP. 140/80 PR.100 RR. 24 Rales at lung dextra and sinistra Lab: Leuco:12.600 Neutrofil:86.6% CXR: Infiltrate, airbronchogram
-Diet DM 1700 kkal/day, low salt <2 gr/dl -inj. Insulatard 0-0-10 iu sc -inj. Actrapid 4-4-4 iu sc
-O2 2-4 Lpm via NC -Inj. Ceftriaxone 2x1 gr -inj. Ciprofloxacin 2x200 mg (adjusting dose)
PL
Idx
PDx
PTx
-diet DM 1700 kkal/day, low salt < 2gr/dl -weight reduction
PMo
Subjec tive
Female/65 yo Ureum: 80.6 Creatinin: 1.88 BUN: 20.1 UOP. 25 cc/hour Female/65 yo Blurred vision since 5 years ago History of DM since 10 years ago, not routinely controlled
5.1. dt no 1
Subj VS ureu
6.1 DM nephropathy
PL
Idx
PDx
Echocard iografi
PTx
-O2 2-4 lpm -semifowler position -diet DM 1700 kkal/day, low salt < 2gr/day -Po: captopril 3x25mg
PMo
Subjec tive VS UOP
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