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Morning Shift Report

Saturday, 16-11-2013

dr.Dikara

Physician In Charge:

1A : dr. Dikara, dr. Hesti dr. Fitranti (Cardio)

1B : dr. Herman, dr. Nanik T

II : dr. Rifai

III : dr. Sri Sunarti, Sp.PD

Summary of Data Base

Female 60 yo/ w.28

Chief complain : Diarrhea

Patient suffered from diarrhea since one day before admission, frequency about more than10x/day, watery > residual feces, volume about 1/2 glass of mineral water, without blood (-

), foam (-) ,but with mucous (+) accompined some times with epigstric pain.

She said about diarrhea, fist diarrhea like wash rice and mucous but since today diarrheawatery > residual feces , and persist with mucous.

She did not eat something that different from daily food. She also complained felt thirstysince diarrhea

She have hypertension since 7 month ago, BP about 140/-, but she didnt took drugbecause she didnt felt anything. History of hospitalization before was unknown

History of social living: she is a house wife with 4 childrenPhysical Examination

Ward BP = 130/90 mmHg PR = 88 bpm, regular, strong RR = 18 bpm Tax : 36,9C

General appearance looked moderate ill GCS 456

Head Pale conjunctiva (-) Icteric sclera (-)

Neck JVP R + 0 cmH2O 30 degree

Chest Heart: Ictus invisible and palpable at ICS V MCL S

LHM ictus RHM: SL D

S1, S2 single, murmur (-)

Lung: Symmetric, SF D=S, normal percussion,

Rh - - Wh - -

- - - -

- - - -

Abdomen Soefl, bowel sound (+) increase, liver span 8 cm, traubes space thympani,

shifting dullness ( - ), epigastric tendenners (+)

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Extremities Leg edema -/- , warm acral

Laboratory Findings (November 16th 2013)

LAB VALUE NORMAL LAB VALUE NORMAL

Hemoglobin 15.10 11,0-16,5 g/dl RBS 86 < 200 mg/dl

MCV

MCH

81.80

28.90

80-96 fl

26,5-33,5 pgUreum 21.60

10-50

mg/dL

Leukocyte 10.520 3.500-10.000/L Creatinine 1.020,7-1,5

mg/dL

Eo/Bas/Neu/Limf

/Mon

1.0/0.2/80/

12.6/6.0

0-4/0-1/51-67/25-

33/2-5Natrium 136

136-145

mmol/L

PCV 42.70 35-50% Kalium 3.96

3,5-5,0

mmol/L

Trombocyte 236.000 150.000-390.000/L Chlorida 11098-106

mmol/L

SGOT 29 11-41U/L

SGPT 30 10-41U/L

ECG ( November 16th2013 )

Sinus rhytm with HR 90 bpm Frontal Axis : Norml Horizontal Axis :Normal PR interval : 0.16 QRS complex : 0,08 QT interval : 0,32

Conclusion : Sinus rhytm HR 90 bpm

CXR ( November 16th2013 )

AP position, symmetric, enough KV, enough inspiration

Soft tissue and bone: normal

Trachea in the middleSinus phrenicocostalis dextra and sinistra dome sharp

Hemidiaphragma dextraand sinistra dome-shape

Lung: BVP normal,Cor: site N, cardiac waist (+), size: CTR=45%

Conclusion: Normal CXR

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CUE AND CLUE PL IDx PDx PTx PMo PEd

Female/ 60 yo/W.28

A

Diarhea since

yesterday >10x/d

Nausea

Vomiting

Residual feces (+)

Mucous (+)

PE

TD: 130/90

N: 88 strongRR: 18

Bowel sound (+)

Epigastric tendenerrs

(+)

At 08:45 PMurination

Lab:

Leu: 10.520

Neu: 80.0%

Na: 136

K: 3.96

Cl: 110

Ur: 21.60

Cr: 1.02

Daldiyono score: 1

1. Acute

inflamm

atory

diarhea

with

mild

dehydra

tion

1.1 EIEC

1.2 Shigelosis

1.3

Salmnelosis

Fecal

culture

and

sensitiv

ity

Low fiber diet

1700kkal/day

IVFD NaCl 0.9%20dpm

Inf. Ciprofloxacin 2x400

mg IV

Inj. Metoclopramid 3x10

mg (PRN) IV

PO:

Ataplugit 2 atblet every

diarrhea, maximal 10

tablet/day

S, VS,

urine

produ

ction

Higine,

low fiber

diet.

Female/ 60 yo/W.28

AHistory f HT since 7

month ago

BP about 150/-

PE

TD: 130/90

N: 88 strong

RR: 18

ECG: sinus rhytm 90

bpm

2.

Historyof HT

Fundus

copy

Low salt diet