September, 25th 2017

Physician in charge:

Ulfia Azmi
Mustika Hany R
Henny Dwi
M. Rizaldi
 Patient Identity

 Name : Mr. L
 Sex : Male
 Age : 52 y.o
 Religion : Islam
 Tribe : Banjar
 Nation : Indonesia
 Address : Bati-bati
 Occupation : private employees
Date of Hospitalization : September, 24th 2017
 Autoanamnesis and
heteroanamnesis
Chief complained : loose stool
Autoanamnesis:

Patient complained has lost stool since 4 days ago, >4x/day,
the stool is dominantly water, there is no blood and mucus in the
stool. Patient also complained has vomited since 4 days ago,
>5x/day, the composition of vomit are drool and food. Patient
has had fever, 4 days ago, on and off, he has headache too. At ER
patient’s condition was weak, his skin turgor decreased, and
sunken eyes. Patient’s skin is itchy, swollen, pale red bumps all
over his body and extremity after consuming cefixime. Patient
has decreased of appetite since 5 days ago.
Patient has history of diabetes mellitus since 4 years ago, and
consumes metformin, glimepiride and insulin injection 1x/week.
Patient also has diabetic foot.
 Autoanamnesis

 History of past illness: -


 History of family illness: -

 History of drug: (-)

 Allergic History : (-)

 Smoking History: (-)

 Social history : patient lives with his wife and 5 children.

 Physical Examination (September, 24th 2017 )
TD: 110/70 mmHg HR: 96 x/mnt reguler, RR : 25x/mnt reguler Tax : 36.5 0C
SpO2: 98%
General appearance : General moderate ill GCS 4-5-6
Skin
Head

Reduce skin turgor (+), papul eritem on body and extremity (+)
Pale Conjungtiva (-), Sclera icteric (-), sunken eyes (+)
Neck JVP R+2 cmH2O, lymph node (-)
Thorax ( Pulmo ) I : Symmetric
Pal : Symmetric, Fremitus Sound D=S
Per : Sonor
A:VV Rh - - Wh - -
VV - - - -
VV - - - -
Cor I : Ictus Invisible
Pal : Ictus Palpable at ICS V MCL Sinistra
Per : LHM : ICS V MCL Sinistra
RHM : ICS IV Linea Sternalis dextra
A: S1 S2 single, Murmur (-)
Abdomen Bowel sound (+) 15”/ M, Hepatomegali(-), Spleonomegali (-),
Undulation (-), Shifting Dullness (-)
Abdominal pain
- + +
- + + 
- - -

Extremities M 5 5 Cold extremity + +

5 5 ++

Wound - -
++
CXR
 September, 24th 2017

 Position PA
 Enough QV
 Less inspiration
 No tracheal deviation
 Soft tissue and bone are normal
 Bronchovasculare pattern is
normal
 No cavitas
 No fibrosis
 Hemidiphragma dome shape
 Costophrenicus angle is sharp
 Cardiophrenicus angle is blunt
 CTR side normal, size %, shape
boot shape with scleroting orta
 ECG

 Sinus tachychardia
 Heart rate : 120x/min
 Frontal axis : normoaxis
 Horizontal axis : normoaxis
 PR interval : normal (0.12s)
 No RBBB or LBBB
 LVH (-)
 Laboratory Result 24-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI


Hemoglobin 12.5 12,50-15,60 g/dl Colorimetric
Leukosit 13 4,65-10,3 thousand/ul Impedance
Eritrosit 4.46 4,10-6,00 milion/ul Impedance
Hematokrit 33.4 42,00-52,00 Vol% Analyzer Calculates
Trombosit 216 150-356 Ribu/ul Impedance
RDW-CV 14 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 75.1 75,0-96,0 Fl Analyzer Calculates
MCH 28.0 28,0-32,0 Pg Analyzer Calculates
MCHC 37.4 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 78.7 50,0-70,0 % Impedance
Limfosit% 14.7 25,0-40,0 % Impedance
MID% 6.6 4.0-11.0 % Impedance
Gran# 10.2 2,50-7,0 ribu/ul Impedance
 Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
GULA DARAH
Gula Darah 327 <200 MG/DL GOD-PAP
Sewaktu
HATI
SGOT 63  0-46 U/l IFCC
SGPT 59 0-45 U/l IFCC
GINJAL
Ureum 118 10-50 Mg/dl Modiff berhelot
Creatinin 4.3 0,6-1,2 Mg/dl Jaffe
ELEKTROLIT
Natrium 116.4 135-146 Mmol/l ISE
Kalium 3.7 3.4 – 3.5 Mmol/l ISE
Chlorida 99.9 95-100 Mmol/l ISE
 CUE AND CLUE PL IDx PDx PTx PMo Ped

Ax: Acute Fecal - IVFD NS 0.9% Vital sign - Drink more

• Loose stool, >4x/day, watery analysis 1,6lt for 2 hours CS water
since 4 days ago diarrhea evaluate Electrolyte
• Vomit >4x/days, [modera


dehydration post
dominated drool and te-heavy status then rehydration
food dehydra - Attapulgit
• Fever on and off tion] 2tab/diarrhea
• Weakness
• Always thirsty
• Decrease urinate
volume
Physical examination:
• Sunken eyes (+)
• Reduce skin turgor (+)
• Abdominal pain (+)
• Bowel sound 15”/m

Ax: DM T II - Levemir 10ui Vital sign -Diabetic diet

• Patient diagnosed with - Atorvastin CS
diabetes mellitus since complica 1x20mg GDP
4 years ago and tion G2PP
consumes metformin
and glimepiride

Lab:
GDS: 327 mg/dl
 CUE AND CLUE PL Idx PDx PTx Pmo Ped
Ax. -ulcus USG Dressing - Protect foot
Patient has wound in his foot, diabetic doppler wound using
history of diabetes mellitus since 4 ABI Score diabetic
years ago Pus shoes
Px. Ulcus diabetic on both foot culture - Foot hygiene


Wagner 3

Lab : - Azotemia - AKI IVFD NS 0.9% - Drink more

Ureum 118mg/dl pre renal 20tpm water
Creatinin 4.3mg/dl

Ax. - Hyponatremia TTV

• Loose stool, >4x/day, since 4 Hiponatrem correction CS
days ago ia IVFD NaCl 3% Elektrolit
• Vomit >4x/days, dominated 20tpm
drool and food
• Fever on and off
• Weakness
• Always thirsty
• Decrease urinate volume
wek
Lab:
Na+ 116.4mmol/l
 CUE AND CLUE PL Idx PDx PTx Pmo Ped
Ax. - Allergic - Inj.
- Hive skin after consuming reaction Difenhydramine
cefixime. 1amp
- Px. - Co.
Papul eritema on his body and dermatovirology


extremity