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Morning Report

Wednesday, April 30th 2015

Coass in charge
Wahyu F

Supervisor: dr. Putu Moda A, Sp.PD


SUMMARY OF DATA BASE
MrsP., 50 yo, W. 28
Autonamnesa and heteroanamnesa (patient’s daughter)
Chief complain: Fever
Patient suddenly has fever since 5 days before admission.
The fever was high and never decrease, but patient never check
with thermometer.
Patient also complain nausea and vomitting. She vomit until
10 times in day before admission. Because of that patient cannot
eat today. She vomit food and beverages that she eaten and drunk.
She never has this complain before suffered fever.
She also complain about headache since has fever. The
headache has no specific location and all day long.
Patient going to hospitals because of her complain, and hospitalized
for 2 days. After go home, she complain fever again, then she come.
Patient consumed paracetamol before going to RSSA.

The patient never suffered problem like this before.


She has no history any disease like DM, hypertension or allergy.

Family Hystory : there are no family with same complain or


condition

Social History :
The patient has married and has 1 child. She is a farmer. There is no
other neighbour or friend that suffered same problem with patient.
PHYSICAL EXAMINATION
General appearance looked moderately ill GCS : 456
Looks normoweight
BP : 130/80 mmHg PR = 72 bpm regular strong RR = 28 tpm Tax : 36 0C
Head Conjuctiva Anemic (-)
Sclera Icteric (-)
Neck JVP R + 0 cm H20, 300 position Lnn. Enlargement (-)
Thorax Ictus invisible & palpable at ICS V MCL S
Heart RHM ~PSL D, LHM ~ ictus
S1 S2 single regular, murmur (–), gallop -

Lung Symetric Stem fremitus D=S Sonor + + v v Rh - - Wh - -


++ v v - - - -

++ v v - - - -

Abdomen Flat, Bowel Sound + N, liver span 10 cm,traube space tympani , Shifting dullness (-)

Extremities Edema - - anemic - - Warm acral + +


- - - - ++
CRT < 2 second, Turgor < 2 second
LABORATORY FINDINGS
Lab Value Lab Value
Leucocyte 1.820 4.000-11.000/µL Na 135 136-145mmol/l
Diff Count 0.5/1.1/68. 0-4/0-1/51-67/25-
K 3,52 3,5-5,0 mmol/l
8/21.4/8.2 33/2-5 %
Haemoglobin 13.4 11-16,5 g/dL Cl 97 98-106 mmol/l
MCV 86 80-93 fl
MCH 28,9 27-31pg Ureum 18,5 16,6-48,5 mg/dL
Hematocrit 39,8 38-42 % Creatinin 0,86 < 1,2 mg/dL

Thrombocyte 28.000 142-424x103/µL


SGOT/AST 121 0-41U/L RBS 92 < 200 mg/dL
SGPT/ALT 78 0-41U/L
P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
Female, 50 yo 1. AFI day 5 + 1.1 Dengue IVFD Asering Pmo:
Fever since 5 days ago thrombocytop Fever 1000 cc in 2 Subjective
Nausea and vomitting enia 1.2 Other hours Vital sign
since 5 days ago arboviral Then DL/12 hours
Headache since 5 days infection IVFD Asering Urine output
ago 20 dpm Fluid overload
Consumed paracetamol sign
before going to RSSA Paracetamol
3x500mg prn P.Edu:
PE: Disease
BP: 130/80 mmHg Therapy
PR: 72 bpm Prognosis
RR: 28 tpm
Tax: 36,2 C

Lab :
WBC: 1.820
Trombocyte: 28.000
SGOT: 121
SGPT: 78
P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
Female, 50 yo 2. Nausea and 2.1 dt Inj Pmo:
Nausea and vomitting vomitting Dengue metoclopram Subjective
since 5 days ago Fever ide 3x10 mg Vital sign
vomit until 10 times 2.2 acute
vomit food and gastritis PO P.Edu:
beverages that she Omeprazole Disease
never has this complain 2x20 mg Therapy
before Prognosis

PE:
BP: 130/80 mmHg
PR: 72 bpm
RR: 28 tpm
Tax: 36,2 C

Lab :
WBC: 1.820
Trombocyte: 28.000
SGOT: 121
SGPT: 78
THANK YOU….