DR.

YASMITA-PPDS IPD

MORNING REPORT July 3rd,2012

JAGA 1A : dr. Yasmita, dr. Camelia , dr. Galuh(cardio) JAGA 1B : dr. Asri , dr. Merici JAGA 2 : dr. Satriyo JAGA 3 : dr. Didi Candradikusuma, SpPD MODERATOR : dr. Atma Gunawan, SpPD-KGH

SUMMARY OF DATA BASE

Ms. Dwi /20 yo/W24A Chief complain: fever Px suffered from fever since 3 days before admission, high grade fever, never reach normal temperature although already consumed drugs from GP before. She went to GP 1 day before admission, got 3 kinds of drugs(bimaflox,antalgin,other drug). But the complaint not relieved, then she went to RSSA She complained about headache since 4 days ago, esp.middle area of head, continously.

Complained about nausea and vomitting since 2 days ago, vomit 2x, contain food, that made her decrease of appetite, only ate 3-4 spoon/each Complained about nose bleeding at 1 day before admission, about a quarter of glass Px had sakit maag since the last 2 years, often use promag to relieved the pain Px is a college student in UB

PHYSICAL EXAMINATION
BP = 130/70 mmHg PR = 88 bpm, reguler RR =20 tpm Tax : 37.6C
General appearance looked moderately ill Head Neck Thorax: Cor: Anemic JVP R + 0 cmH2O 30 Invisible and palpable at ICS V MCL Sinistra RHM SL Dextra LHM ictus S1 S2 single Simetric, SF D = S, no additional breath sounds GCS 456 looks normoweight Icteric -

Lung:

Abdomen Extremities

Soufle, BS (+) Liver span 8 cm, traubes space thympani anemic -, acral warm, RL (+)

LABORATORY FINDING Lab Value Lab Value

(Normal) Leukocyte 3990
3.50010.000/L

(Normal) 136-145 mmol/L

Natrium

Haemoglobine 15.2
PCV Trombocyte 45.1 41000

11,0-16,5 g/dl
35-50% 150.000390.000/L

Kalium
Chlorida RBS

3,5-5,0 mmol/L
98-106 mmol/L < 200 mg/dl

SGOT

524

11-41U/L

Ureum Creatinine

10-50 mg/dL 0,7-1,5 mg/dL

SGPT

207

10-41U/L

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female/20yo Febris day 3 Headache Nausea and vomitting PE: BP. 130/70 PR.88 RR. 20 S. 37.6C Warm acral Rumple leed + Lab: Hb 15.2 Leuco 3990 PCV 45.1 Trombo 41000

1. AFI day 3+thromb ocytopeni a

1.1 Dengue hemorrhagic fever grade II 1.2 chikungunya 1.3 ricketsiosis 1.4 other arboviral infection

IVFD RL 30 dpm Soft diet 1900 kkal/day Surface cooling Inj. Metochlopramid 3x10mg

Subjecti ve BP HR RR CBC bleedin g

CUE AND CLUE

PL

Idx
2.1 due to no 1 2.2 gastritis erosive

PDx

PTx
Inj. Metochlopramid 3x10mg Po: omeprazole 2x20mg

PMo
Subj.c omplai ned

Female/20 yo 2. Dyspepsia Nausea and vomitting syndrome Epigastric pain

Female/20 yo SGOT 524 SGPT 207

3. Increase of transaminas e

3.1 reactive 3.2 viral hepatitis

HbsAg Anti HCV

Confirm dx

SGOT SGPT

THANK YOU

Condition this morning

Fever (-) BP. 120/80 PR. 90 RR. 20 Tax. 37 Warm acral