dafri (dr melissa)

8/16/2019 DAFRI (Dr Melissa)

1/10

Duty Report4th May , 2016


2/10

Dafri, 33 y.o, male, MW 10

Cc:◦ Breathlessess icrease sice 1 !ay a"o

#reset $lless %istory

◦

Breathlessess icrease sice 1 !ay a"o, ofte felt sice 2moths a"o, ot i&uece! 'y acti(ity, )eather or foo!

◦ %istory of ofte star(i", thirsty a! micturitio at i"htsice 6 moths a"o

◦ Decrease of 'o!y )ei"ht sice 6 moths a"o

◦ Cou"h sice 2 moths a"o, sputum *+ cou"h *-

◦ e(er come a! "o sice 2 moths a"o

◦ Micturitio are ormal, pai *-

◦ Blurre! (isio *-

◦ /um'ess at etremity *-


3/10

%istory of DM sice 2 mothsa"o, "ot metformi 300 m",'ut patiet !i!t tae it re"ularly

%istory of hypertesio *- B *-asthma *-


4/10

#hysical 5amiatio

Cosciousess le(el: CMC

B# : 10070

%R : 2 mi

RR : 28miute

: 37oC


5/10

9i : tur"or is ormal

5ye

◦ Coucti(a are aemic --

◦ 9clera are icteric --

/ec

◦ ;


6/10

Cor: $spectio: ictus is ot see.#alpatio: ictus is palpate! at 1 @"erme!ial =MC9 $C9 <

#ercussio:=eft 'or!er: 1 @"er me!ial =MC9 $C9 <

Ri"ht 'or!er: liea steralis !etra

Apper 'or!er: R$C $$>uscultatio: pure rhythm, murmur *-


7/10

>'!ome:◦

$spectio: elar"emet *-◦ #alpatio: li(er a! splee upalpa'le◦ #ercussio: timpai◦ >uscultatio: 'o)el sou! *+ ormal

la : oci" a! pressure pai atC --

5tremities:◦ #hysiolo"ic Re&e ++◦ #atholo"ic Re&e --◦ 5!ema --


8/10

=a'oratory

%' 11

WBC%t hrom'ocyte

RBAreumcreatiie/aClCaB>p%

pC2p2%C3-B5 ecf 9a2

1E40034F347000

301642,61213,8E4E,3

7,3

3441E,4-6,47EF


9/10

Wori" Dia"ose

Brochopeumoia *C># )ithrespiratory failure type 1

>$ ri&e $ c.' prereal c.' !ehy!ratio

ype 2 DM ucotrolle! ormo)ei"ht9usp lu" B

>symptomatic 'ra!icar!ia


10/10

herapy

Rest!aily !iet DD 1E00 al/RM10lmi

$ cefopera?oe 21

#aracetamol 300m"

/ acetyl sistei 3200m"

$ le(emir 110 uit sc

dafri (dr melissa)

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