MORNING REPORT

Kamis, 9 Oktober 2014

Co Ass in charge :
Lisa Wiramas
Alex Christianto
Adilah Ulfiati

MODERATOR : dr. Ungky Agus S, SpP

 Summary of Data Base
Mrs. Atik Utami/43 y.o/w.28

Chief Complaint: diarrhea and fever

History of present illness :
Patient suffered from fever and diarrhea that started 2 days ago, with
frequencies more than 5 times per day. The feces were watery, with yellow-
greenish colour,there was a little blood and mucous in the stool. Patient also
suffered from abdominal pain on all area. She also felt nauseous and vomit
everytime she eats.

History of Past Illness:

Patient had CAPD attached to her from 1,5 years ago, the fluid colour is
cloudy. Patient suffered from CKD from 1,5 years ago and has never
complained about this before. She suffered from hypertension and has never
complained about this after the CAPD attachment. She did dialysis regularly.
Family history:
None of her family had suffered from chronic kidney disease.

Social history:
She was a housewive with two kids
PHYSICAL EXAMINATION
BP : 90/50 mmHg PR : 104 bpm, regular RR : 24 tpm Tax : 37.70C

General appearance : looked moderately ill GCS 456

Head Pale conjunctiva (+), icteric (-)

Neck JVP R+0 cm H2O (300)
Thorax : Cor Ictus invisible and palpable at MCL S, ICS V
LHM ~ ictus
RHM: SL D
S1, S2 single with no murmur

Pulmo Symetris, stem fremitus D=S, rhonki -I- Wh -I- ves +I+
-I- -I- +I+
-I- -I- +I+
Abdomen bowel sound N, tenderness (+), bruit (-), liver span 8 cm, traubes
space tympanic, shifting dullness (+), CAPD catheter attached,
Extremities Warm acral +
LABORATORY FINDING
Result Normal Value
Leucocyte 7,430 /l 3.500 10.000
Hemoglobine 5,70 gr/dl 11.0 16.5
: MCV 56,40 mm3 80-93 fL
MCH 16,90 pg 27-31 fL
PCV 19,00 % 35 50
Trombocyte 333.000 /L 150.000 390.000
RBS 159 mg/dl < 200
Ureum 26,90 mg/dL 10-50
Creatinine 1,22 mg/dL 0.7 1.5
SGOT 46 U/L 11 41
SGPT 36 U/L 10 41
Albumine 3,31 g/dl 3.5 5.5
Na 125 mmol / L 136 145
K 3,68 mmol / L 3.5 5.0
Cl 108 mmol / L 98 106
Bil total 0,72 mg/dL
Bil direk 0,51 mg/dL
Bil indirek 0,21 mg/dL
HBsAg positive
HbsAg Positif

Anti HCV Negatif

AFP 2,51 7.0

PPT 11,6 s 11,4 s

INR 1.00

APTT 25,2 s 25 s
URINALYSIS
Result Result
SG 1,025 10 x

PH 6,0 Epithelia 9,2

Leucocyte 1+ Cylinder +
Nitrite - Hyaline -

Protein 3+ Granular -

Glucose - Leukocyte -

Erythrocyte 3+ Erythrocyte -
40 x
Keton urine trace Eritrosit 320,7
Urobilinogen - Leukocyte 68%
Bilirubin - Crystal -
Bacteria 54,6 X103 ml x103/ml
ECG (22-7-2013)
ECG (July 22rd 2013)

Sinus rythm, Heart rate 120 bpm

Frontal Axis : normal
Horizontal Axis : normal
PR interval : 0.16
QRS complex : 0.04
QT interval : 0.28

Conclusion: sinus tachycardia with heart rate 120 bpm

CXR (July, 22nd 2013)
AP position, asymmetric, enough KV
Soft tissue thin, bone normal
Trachea in the middle
Hemidiaphragma D elevated, Hemidiaphragma S covered by cardiac
shadow
Phrenico costalis angle D sharp, and Phrenico costalis angle S sharp
Pulmo D : looked normal
Pulmo S : looked normal
Cor: site N, cardiac waist (+), size CTR 49 %
Conclusion : looked normal CXR
USG Abdomen (12-3-2012)
Conclusion
 CUE AND CLUE PL IDx PDx PTx PMo Ped

Female/ 43 yo 1.Abdomi 1.1 Peritonitis - - Abdomi Bed rest

Ax: nal pain nsl pain -
-Abdominal pain on all area on all prognos
--nausea and vomitting area is
-CAPD attached
PE:
-bowel sound N,
tenderness (+) on all area,
bruit (-), liver span 8 cm,
shifting dullness (+)
Lab:
 CUE AND CLUE PL IDx PDx PTx PMo Ped

Male/ 58 yo 2.Acute 2.1.ETEC Fecal -Soft diet 1900 kcal/day, low fiber VS Took
Ax: waterry 2.2.Rotavirus analysis, BJ -IVFD NaCl 0,9 % 500 cc in 1 hour drink
-waterry diarrhea > 5 times diarrhea infection plasma then 20 dpm every
per day contained mucous, PO: attapulgite 2 tablet every diarrhea diarrhea
yellowish colour, blood
since two days ago.
-
-PE:
-bowel sound N, skin turgor
N
 Management Analysis
1. Emergency : -

2. Urgency:
-IVFD NaCl 0,9 % 500 cc in 1 hour then 20 dpm
3. Non-urgency:
-Anemia hypochromic microcyter: treat underlyng disease
-Inj. Metoclopramide 3x10 mg
-Inj. Ranitidin 2x50 mg
-PO: paracetamol 500mg/kodein 20 mg 3x1 tablet
attapulgite 2 tablet every diarrhea

s
Thank You!

L/O/G/O