Morning report

Wednesday, September 22’nd, 2010

PHYSICIAN INCHARGE:
IA : dr. Nicholas dr. Rusyda
IB : dr. Tantri, dr. Vindrya
II : dr. Aries
III : dr. Shinta, SpPD
 Summary of database
• Male/53 yo/W.24A
• Chief complain: fever
• Patient suddenly had a high grade fever since 3 days ago,
continuously. But since yesterday, patient did not have fever
anymore because she took Paracetamol.
• Patient also complain about epigastria pain. He felt nausea, so
he had lose of appetite. But since today, he got his appetite
back.
• There was no sign of bleeding.
 Physical examination
BP = PR = RR = Tax : 37,3 °C
110/70 mmHg 78 bpm 18 tpm

General appearance looked moderatelyill GCS 456

Head Anemic - Icteric -

Neck JVP R + 0 cm; 30°

Thorax: Cor: Ictus invisible and palpable at 2 cm medial MCL ICS V Sinistra
RHM SL Dextra
LHM ≈ ictus
S1, S2 single with no murmur

Lung: Simetric, SF D = S, v v Rh - - Wh - -
vv -- --
vv -- --

Abdomen Flat, soft, liver span 8 cm, troube space tympani

Extremities Warm
 Laboratory findings
Lab Value Lab Value

Leukocyte 2.400 3.500-10.000/µL Natrium 130 136-145 mmol /

L
PCV 41,3 35-50% Kalium 3,96 3,5-5,0 mmol / L

Trombocyte 81.000 150.000- Chlorida 97 98-106 mmol / L

390.000/µL
SGOT 46 11-41U/L RBS 123
SGPT 32 10-41U/L

Urinalysis

SG: 1,015 pH: 5 Protein: 2+ Glucose: - Keton: - Ery: 5+

Leu: 3+ Ery: 30-35/hpf Leu: >100/hpf Bacteria: ++ Nitrite: +
 CUE AND CLUE PL IDx PDx PTx PMo

Male/53 yo 1. AFI + 1.1.Den Den •Bed rest Subjective

•Fever, acute, high grade, bisitopen gue gue •Free diet BP
continuously 3 days ia fever NS1 •Surface cooling HR
•L: 2.400 •IVFD RL 30 dpm RR
•Tr: 81.000 Tax
•PCV: 41,3

Male/53 yo 2.Dyspep 2.1.due •Metoclopramide 3x10 mg (iv) Subjective

•Epigastria pain sia to No.1 •Omeprazole 2x20 mg (po)
•Nausea syndrom
•Lose appetite e