Patients Identity

Name
:
Age
:
Gender
:
Religion
:
Job
:
Address
:
MR number :
Room
:
Entry date :
Date out
:

Mrs. M
57 y.o
Female
Moslem
House wife
Wonosowo RT 04/04 Karang Tengah
01.21.9986
Baitul Izzah I
March 15th, 2014
March 21th, 2014

ANAMNESA
Patient came to emergency room with loss of
consciouness. One day before hospitalize,
patient complain diarrhea > 10 times/day,
blood (-). Patient also complain nausea (+) and
vomitus > 5 times, every vomite about 100
cc/a cup, blood (-). Patient felt this illnes since
3 day ago. Before she suffered from this illnes,
she said that ate unsave food on roadside.
By emergency room doctor, patient sent to ICU
and 12 hours after it patient moved to izzah
wards because the condition is stable.

History of Illness
History of previous illness
Never felt this illness before
Hypertension history (+) 6
years ago
Heart disease history (-)
DM history (-)
Gastritis (+)
Asthma history (-)

Familys history of disease

There is no family have
ilness like her
Hypertension history (-)
DM history (-)
Asthma history (-)
Social Economi History :
Hospital cost certified
by JKN PBI
Economic Impression :
less

Systematic Anamnesis
General
Skin
Head
Eyes
Ears
Nose
Mouth
Throat

: weak
:itching(-),jaundice(+),pale(-), slick (-)
:headache(-)
:blurredvision(-),red eyes(-)
:hearingloss(-),ring(-),discharge(-)
:nosebleed(-),discharge(-)
:cyanosis(-), thrush(-),bleeding gums(-)
:painswallow(-), hoarseness(-), difficult in
swallowing(-)
: enlargement ofthe gland(-)
:cough(-),sputum(-),blood(-) Dyspneau

Neck
Chest
(-)
Cardiac
:chest pain(-),palpitation(-)
Digestive
:decrease apetite , nausea(+),
vomiting(+),
defecate / micsi (>>>/+)
Musculoskeletal
:weak(-),rigid(-),back pain (-)
Extremity
: oedem extremity ( -/-)

Physical Examination
General Status
General
Awareness

: weak
: Composmentis

Nutrient Status
Height
Weight
BMI

= 162 cm
= 50 kg
= BB(kg)/TB(m)
= 50 kg/(1,62 m)
= 19, 08 (Normoweight)

 Vital Sign
o Blood Pressure : 120/70 mmHg
o Heart rate
: frequ. 88 x/minutes, regural ritmict, strong
amplitudo, same equality, elastic arterywall,
pulsus alternans (-), pulsus defisit (-)
o Breath Frequency
: 24 x/minutes
o Temp
: 38,3o C
Head
: Mesocephal, alopesia (-)
Eyes
Nose

: Anemic Conjuntiva (-/-), Icteric sclera(-/-)

: symmetric, secret (-), Nostril Breath (-)

Ears: Normal Shape, discharge (-/-)

Esophagus : Hyperemic (-), pain devour (-)
Mouth
: Cyanosis (-), dry lips (+)
Neck
Skin

: Trakhea deviation (-), Lymph Hypertropy (-)

: poor skin turgor

Extremity : Oedem of lower extremity (-), Oedem of

upper extremity (-)

Thorax-Lung
INSPE
KSI

ANTERIOR

POSTERIOR

Static

RR : 24 x/min, Hyperpigmentation
(-), spider nevi (-), atrofi M.
Pectoralis (-), Hemithoraks D=S, ICS
Normal, Diameter AP < LL

RR : 24 x/min,
Hiperpigmentasi (-), spider
nevi (-), Hemithoraks D=S, ICS
Normal, Diameter AP < LL

Dinamic

Up and down of hemitoraks D=S ,

abdominothorakal breathing, (-),
muscle retraction of breathing (-),
retraction ICS (-)

Up and down of hemitoraks

D=S, abdominothorakal
breathing (-), muscle
retraction of breathing (-),
retraction ICS (-)

Palpatio
n

Palpation pain (-), tumor (-), Arcus

costae angle < 900, enlargemnet of
ICS (-), Stem fremitus D=S

Palpation pain (-), tumor (-),

Stem fremitus D=S

Percutio
n

sonor

Sonor

ausculta
tion

Vesicular sound (+), wheezing (-),

ronchi (-)

Vesicular sound (+), wheezing

(-), ronchi (-)

Interpretation : normal

THORAX - COR
INSPEKSI
Ictus cordis cant be seen
PALPATION
Ictus cordis is palpable at ICS V, 2 cm medial from linea mid clavicula
sinistra, thrill (-), pulsus epigastrium (-), pulsus parasternal (-), sternal
lift (-)
PERCUTION
Dull sound
: ICS II linea sternalis sinistra
Upper borderline
: ICS III linea parasternalis sinistra
: ICS V linea sternalis dextra
Waist
: ICS V, 2 cm medial from linea mid clavicula
sinistra
Lower right
borderline
Lower left
borderline
AUSKULTATION
Aorta valve

: S1 & S2 standart, additional sound (-), AI<A2

: S1 & S2 standart, additional sound (-), P1<P2
Interpretation
: normal
Pulmonal valve
: S1 & S2 standart,
additional sound (-), T1>T2

ABDOMEN
1.Inspection
2.Auskultasi
3. percussion
4. palpation

convex of surface(+), sycatric(-), striae(-),

enlargement of vena (-), caput medusa (-)
peristaltic (15x/minutes), bising aorta
abdominal, A. Lienalis, A. femoralis (-)
tympani all abdominal surface,
Liver span : dex = 8cm ; sinistra = 6cm, area
troube (+)
Superfisial : supel, massa (-)
Deeper : pain (+) on lower regio abdominal ,
hepatomegali (-), Spleenomegali (-) Murphys
sign (-)

interpretation : pain on lower regio abdominal

Extremity
Ekstremity

Superior

Inferior

Oedem

-/-

-/-

Cold extremities
Physiological
Reflect
Ikteric

-/-

-/-

+/+

+/+

-/-

-/-

Impression

normal

Laboratory Result March 15th,

2014

Chemical
GDS

67

mg/dl

75 100

Uric Acid

12.4

mg/dl

2.6 5.7

Ureum

64

mg/dl

10 50

Creatinin

1.63

mg/dl

0.5 0.9

Total Bilirubin

0.66

mg/dl

0.1 1.0

Bilirubin Direct

0.15

mg/dl

0 0.2

Bilirubin
Indirect

0.51

mg/dl

0 0.75

Total Protein

8.50

g/dl

6.0 8.0

Albumin

4.06

g/dl

3.4 4.8

Globulin

4.44

g/dl

SGOT

94

U/l

0 35

SGPT

41

U/l

0 - 35

Natrium

137.2

mmol/L

135 147

Kalium

3.27

mmol/L

3.5 - 5

Chloride

109.4

mmol/L

95 105

Calcium

8.5

mg/dl

8.8 10.8

Magnesium

2.2

mg/dl

1.6 2.4

Cont...
Cholesterol

91

mg/dl

<200

Trigliserid

140

mg/dl

<160

HDL

21

mg/dl

37 92

LDL

31

mg/dl

60 - 130

Imunoserology
HBsAg

Non Reaktif

Non Reaktif

Blood Gas Analyze

FIO2

61.0

pH

7.483

pH (37C)

7.483

pCO2

21.5

mmHg

pCO2 (37C)

21.5

mmHg

pO2

243.7

mmHg

pO2 (37C)

243.7

mmHg

SO2%

99.9

94 98

HCT

36

35 45

Hb

12.1

mmol/L

BE ecf

-7.4

mmol/L

BE b

-4.7

mmol/L

SBC

20.5

mmol/L

7.37 7.45

33 44

71 104

-2 - +3

Cont...
HCO3

16.3

mmol/L

22 29

TCO2

16.9

mmol/L

23 - 27

411.1

mmHg

A-aDO2

167.4

mmHg

a/A

0.6

RI

0.7

V%

O2 Cap

16.8

mL/dL

O2Ct

17.5

mmol/L

Lactate

1.7

mmol/L

Calsium ++

1.08

mmol/L

Interpretation :
Leukositosis
Neutrofilia
Limfopenia
Hipoglikemi
Hiperurisemia
Hipokalemi
Hipokalsemia
Increase SGPT SGOT
azotemia
Asidosis metabolic

EKG

Interpretation
Rhythm
Frequency
Axis
Zona transisi
P wave
PR Interval
QRS complex
ST Segment
- ST elevation
- ST depression
T wave
-T inverted
-T tall
Impression

:
:
:
:
:
:

: Reguler
1500/12 kk =125x/min
NAD ( Normo Axis Deviation )
V3
normal 0,08
normal 0,12
normal 0,08

::::: Sinus tachycardi

CHEST X-RAY

Interpretation :
Cor
: Normal
Pulmo : Normal

Data Abnormality
Anamnesis
1.Loos of
conciouness
2.Diarrhea > 10
times/day
3.Green stool
4.Nausea
5.Vomitus > 5 times
6.Decrease appetite
7.Weak
8.Lower abdominal
pain
9.Hypertension
history
10.Gastritis history

Physic Examination
12. t = 38,3
13. Dry lips
14. Poor turgor skin
15. PF abdomen =
pain on lower regio
abdominal

Advance
examination
Lab :
16. Leucocytosis
17. Neutrofilia
18. Limfopenia
19. Hiperurisemia
20. Hipokalemia
21. Azotemia
22. Asidosis
metabolic
23. EKG : sinus
tachycardi

infeksi

leukosito
sis

Diare >
10x,
muntah
dehidrasi

Gangg.
elektrolit
Hipokalemi
Hiperclorid
e
hipokalsem
ia

Syok
hipovolemia
Ureum
creatinin
meningk
at

UNCONCIOUSN
ESS

unconcious
ness
Asidosis
metaboli
k
Alkalosis
respirator
ik

Kerusakan
hepar
Test fungsi
hati
abnormal
(HDL turun)
Gangguan fungsi
hepar
(SGOT SGPT
meningkat)

Problem list
1. Se
2. Acute diarrhea with severe
dehydration
3. Hipokalemia
4. Hiperurecemia

Unconsiouness
Ass :
Non cerebral
Syok hipovolemia
Sepsis
Gangguan elektrolit

 Intial Plan Diagnosis :

PCR, electrolit test, urin test, kultur darah, kultur sensitivitas.
Initial Plan Therapy :
- 02 6-10 liter/minutes
- Ceftriaxone
- inf. RL loading dose 2000cc40tpm
- Paracetamol 3x500
Ip. Monitoring :
GCS, vital sign, balance cairan, electrolit, PH darah
IP. Ex :
- Edukasi kepada keluarga mengenai penyakitnya dan
komplikasinya

Acute diarrhea with severe

dehydration

Ass
: diagnosa etiology bacteri: e.coli, salmonella typhi, disentri amobiasis,
cholera, travelling
gastroenteritis, food intoxication
complication asidosis metabolic, syok hipovolemic, acute kidney disease
IpDx
IpTx

: feces routine, stool culture

: Rehidration RL, loading dose = 2ooocc 40 tpm
- Ceftriaxone

- Loparamide 2mg 3 x 1

IpMx
: vital sign, fluid balance, dehydration symptom, peristaltic sounds
IpEx
:
Eating small meals and snacks often throughout the day is usually easier to tolerate than
eating large meals two or three times a day.
Drink and eat high-sodium foods, such as broths, soups, sports drinks, crackers, and pretzels.
Some sports drinks can help replace electrolytes lost through persistent diarrhea.
Drink and eat high-potassium foods, such as fruit juices and nectars, potatoes without the
skin, and bananas.
Drink at least 1 cup of liquid after each loose bowel movement.

Hipokalemi
Ass :
IP.Dx : electolit test, EKG
Ip. Tx :
non pharmacology : diet high calium
pharmacology : KSR 3x600 mg
Ip. Mx : electrolit test everyday
Ip. Ex : - diet high calium (banana,
avocado, tomato)
Kebutuhan kalium 4,6

HIPERURISEMIA
Ass :
IP. Dx: uric acid
IP. Tx:
Farmakologis
allupurinol 2x100 mg

IP. Mx:
Lab : uric acid, GFR,
IP. Ex :
Consumption drug regularly
Avoid high purin intake

Kelainan test fungsi hepar

Ass : fatty liver, hepatitis
Initial Plan Diagnosis :
USG abdomen, Biopsi
Intial Plan Therapy :
- curcuma 2x200 mg
Intial Plan Monitoring :
SGPT, SGOT, alkali fosfatase, albumin
Intial Plan Education :
diet low cholesterol

Follow up
15/03/20 16/03/2 17/03/2
19/03/20 20/03/20 21/03/20
18/03/2014
14
014
014
14
14
14
T
D

122/70
mmhg

130/80 120/70
mmhg mmhg

110/ 80
mmhg

102
88
116
72
x/minut x/minute
H
x/minutes
x/minutes
es
s
R
39 x/
29 x/
32 x/
R
minutes minutes minutes
R
38,2
t

37,5

37,3

120/70
mmhg

120/80
mmHg

120/80
mmHg

86
76
80
x/minutes x/minutes x/minutes

22 x/
minutes

20 x/
minutes

36,2

36,3

24
22
x/minutes x/minutes
36,4

36,2

WASSALAMUALAIKUM