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Physical examination
BP = 150/90mmHg PR = 84 bpm RR = 18 tpm General appearance looked moderately ill GCS 111456 Looked normoweight Head Neck Thorax: Heart: Anemic Icteric -
JVP R + 0 cmH2O; 30 Ictus invisible and palpable at ICS V MCL sinistra LHM: ictus RHM: SL S1, S2 single with no murmur Symmetric, SF D = S s s ss ss v v v v v v Rh - - - Wh - ---
Lung:
Abdomen
Soefl, liver span 8 cm, troube space tympani, bowel sound normal Warm
Extremities
Laboratory finding
Lab Value Lab Value
Leukocyte
Haemoglobine PCV
13,200
14.8 45
3.500-10.000/L
11,0-16,5 g/dl 35-50%
Natrium Kalium
152 3.91
Trombocyte
Ureum Creatinine
267,000
40.6 0.87
150.000390.000/L
10-50 mg/dL 0,7-1,5 mg/dL
SGPT
Alb CPK CKMB Trop I
18
4.17 200 27 - (0.1)
10-41U/L
ECG (14/10/2011)
Sinus rhythm, heart rate 68 bpm Frontal Axis : Normal Horizontal Axis : Normal PR interval : 0.12'' QRS complex : 0.04 QT interval : 0.32
CXR 141011
CXR (14/10/2011)
AP position, asymmetric Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and hemidiaphragm are dome-shape Aortic knot + Lung: thickening of hillus D/S, fibroinfiltrat in medial area of the lung, infiltrat in apex Cor site, shape are normal, with CTR 46% Conclusion: KP active
CUE AND CLUE Male/74 yo Unconscious 12 hours before admission Excessive sweating Injected insulin 22iu and did not eat 1 hour before unconscious Had been diagnosed diabetes since 3 years ago got insulin GCS 111 456 BP: 150/90 PR: 84 RR: 18 RBG: 15 Leukocyte 13,200 1.
PDx
PTx D40% 50mL (iv) IVFD NS 20dpm Free diet Stop insulin
CUE AND CLUE Male/74 yo Had been diagnosed diabetes since 3 years ago got insulin as his treatment GCS 111 456 BP: 150/90 PR: 84 RR: 18 RBG: 15 Leukocyte 13,200
IDx
PDx
Male, 74yo Had history having blood pressure 150/.. Without theraphy BP 150/90 Male, 74 yo Chronic cough Diagnosed as TBC 1 year ago CXR active KP
Subjective BP
Confirmed diagnosed
Subjective VS
Thank you