Duty ReportFebruary 16th , 2016

murlida, 55 y.o, female, FW 16Cc:

◦Nausea and vomite since 2 days ago

Present Illness History◦ Nausea and vomite since 2 days ago,

vomite about 5-6x/day, ¼-1/3 glass, consist of water and what patient eat, blood (-)

◦ Stomachache (-)◦ Diarrhea (-)◦ Fever (-)◦ Cough (-) breathlessness (-)

Decrease of appetite (+) decrease of body weight (-)

Patient had been known with type 2 DM since 4 years ago, had insulin before and now already given oral diabetic drug

History of hypertension (+) but not routine controlled

Patient had amputation surgery at the right leg since 6 months ago

Physical ExaminationConsciousness level: CMCBP : 160/100HR : 95 x/minRR : 20 x/minuteT: 37,3 oC

Skin : ptechie(-)Eye

◦ Conjunctiva are anemic -/-◦ Sclera are icteric -/-

Neck◦ JVP 5-2 cmH20

Lung: ◦ Inspection: symetric◦ Palpation: fremitus symmetric◦ Percussion: sonor◦ Auscultation:vesicular, rales -/-, wheezing

-/-

Cor: Inspection: ictus is not seen. Palpation: ictus is palpated at 1 finger medial LMCS ICS V (S)

Percussion:Left border: 1 finger medial LMCS ICS V (S)Right border: linea sternalis dextraUpper border: RIC II Auscultation: pure rhythm, murmur (-)

Abdomen:◦ Inspection: enlargement (-)◦ Palpation: liver and spleen unpalpable◦ Percussion: timpani ◦ Auscultation: bowel sound (+) normal

Flank : knocking and pressure pain at CVA -/-

Extremities:◦ Right leg : amputated (+)◦ Left leg : edema (-), physiological reflexes

(+), pathological reflexes (-)

LaboratoryHb 13,9WBCHt ThrombocyteRBGNa/K/ClUr/crUrinalysisBGApHpCO2pO2HCO3-BE ecfSaO2

13.23042%418000350 mg/dl121/3,7/8748/0,8Keton urine (+), proteinuria (-)

7,48377527,64,196%

Working DiagnoseType 2 DM uncontrolled overweight

with ketosisHyponatremia c.b GI lossStage II hypertension c.b essential

TherapyRest/ DD 1700 Kcal low salt IIIVFD NaCl 3% 12 hours/kolf (1 kolf)Inj novorapid 3x8 IU sc, with

correction dosage if RBG 200-300 : + 3 IURBG >300 : + 5 IU

Candesartan 1x8 mgAmlodipin 1x5 mgDomperidone 3x10 mg