Patients Identity

Name
Age
Gender
Religion
Job
Address
MR number
Room
Entry date
Date out

: Mrs. M
: 57 y.o
: Female
: Moslem
: House wife
: Wonosowo RT 04/04 Karang Tengah
: 01.21.9986
: Baitul Izzah I
: March 15th, 2014
: March 21th, 2014

ANAMNESA
Patient came to emergency room with loss of
consciouness. One day before hospitalize, patient
complain diarrhea > 10 times/day, blood (-). Patient
also complain nausea (+) and vomitus > 5 times,
every vomite about 100 cc/a cup, blood (-). Patient
felt this illnes since 3 day ago. Before she suffered
from this illnes, she said that ate unsave food on
roadside.
By emergency room doctor, patient sent to ICU and
12 hours after it patient moved to izzah wards
because the condition is stable.

ICU
Izzah
Wards

Because of loss of conciusess, patient

got Nasogastric Tube for gastric lavage

patient awareness has improved but

still complain weak, nausea, lower
abdominal pain and diarrhea 3 time
Green stool (+)

History of Illness
History of previous illness
Never felt this illness before
Hypertension history (+) 6
years ago
Heart disease history (-)
DM history (-)
Gastritis (+)
Asthma history (-)

Familys history of disease

There is no family have ilness
like her
Hypertension history (-)
DM history (-)
Asthma history (-)

Social Economi History :

Hospital cost certified by
JKN PBI
Economic Impression : less

Systematic Anamnesis
General
Skin
Head
Eyes
Ears
Nose
Mouth
Throat
Neck
Chest
Cardiac
Digestive
Musculoskeletal
Extremity

: weak
: itching (-), jaundice (+), pale (-), slick (-)
: headache (-)
: blurred vision (-), red eyes (-)
: hearing loss (-), ring (-), discharge (-)
: nosebleed (-), discharge (-)
: cyanosis (-), thrush (-), bleeding gums (-)
: pain swallow(-), hoarseness (-), difficult in
swallowing (-)
: enlargement of the gland (-)
: cough (-), sputum (-), blood (-) Dyspneau (-)
: chest pain (-), palpitation (-)
: decrease apetite , nausea (+), vomiting (+),
defecate / micsi (>>>/+)
: weak (-), rigid (-), back pain (-)
: oedem extremity ( -/-)

Physical Examination
General Status

General

: weak

Awareness

: Composmentis

Nutrient Status
Height
Weight
BMI

= 162 cm
= 50 kg
= BB(kg)/TB(m)
= 50 kg/(1,62 m)
= 19, 08 (Normoweight)

 Vital Sign
o Blood Pressure
o Heart rate

o Breath Frequency
o Temp
Head

: 120/70 mmHg
: frequ. 88 x/minutes, regural ritmict, strong
amplitudo, same equality, elastic arterywall,
pulsus alternans (-), pulsus defisit (-)
: 24 x/minutes
: 38,3o C

: Mesocephal, alopesia (-)

Eyes

: Anemic Conjuntiva (-/-), Icteric sclera(-/-)

Nose

: symmetric, secret (-), Nostril Breath (-)

Ears

: Normal Shape, discharge (-/-)

Esophagus

: Hyperemic (-), pain devour (-)

Mouth

: Cyanosis (-), dry lips (+)

Neck

: Trakhea deviation (-), Lymph Hypertropy (-)

Skin

: poor skin turgor

Extremity

: Oedem of lower extremity (-), Oedem of

upper extremity (-)

Thorax-Lung
INSPEKSI

ANTERIOR

POSTERIOR

Static

RR : 24 x/min, Hyperpigmentation (-), spider

nevi (-), atrofi M. Pectoralis (-), Hemithoraks
D=S, ICS Normal, Diameter AP < LL

RR : 24 x/min, Hiperpigmentasi (-),

spider nevi (-), Hemithoraks D=S, ICS
Normal, Diameter AP < LL

Dinamic

Up and down of hemitoraks D=S ,

abdominothorakal breathing, (-), muscle
retraction of breathing (-), retraction ICS (-)

Up and down of hemitoraks D=S,

abdominothorakal breathing (-),
muscle retraction of breathing (-),
retraction ICS (-)

Palpation

Palpation pain (-), tumor (-), Arcus costae

angle < 900, enlargemnet of ICS (-), Stem
fremitus D=S

Palpation pain (-), tumor (-), Stem

fremitus D=S

Percution

sonor

Sonor

auscultatio
n

Vesicular sound (+), wheezing (-), ronchi (-)

Vesicular sound (+), wheezing (-),

ronchi (-)

Interpretation : normal

THORAX - COR
INSPEKSI
Ictus cordis cant be seen
PALPATION
Ictus cordis is palpable at ICS V, 2 cm medial from linea mid clavicula sinistra, thrill (-),
pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-)

PERCUTION
Dull sound
Upper borderline
Waist
Lower right borderline
Lower left borderline

: ICS II linea sternalis sinistra

: ICS III linea parasternalis sinistra
: ICS V linea sternalis dextra
: ICS V, 2 cm medial from linea mid clavicula sinistra

AUSKULTATION

Aorta valve
Pulmonal valve
Trikuspidal valve
Mitral valve

: S1 & S2 standart, additional sound (-), AI<A2

: S1 & S2 standart, additional sound (-), P1<P2
: S1 & S2 standart, additional sound (-), T1>T2
: S1 & S2 standart, additional sound (-), M1>M2

Interpretation : normal

ABDOMEN
1.Inspection

convex of surface(+), sycatric(-), striae(-), enlargement of

vena (-), caput medusa (-)

2.Auskultasi

peristaltic (15x/minutes), bising aorta abdominal, A. Lienalis,

A. femoralis (-)

3. percussion

tympani all abdominal surface,

Liver span : dex = 8cm ; sinistra = 6cm, area troube (+)

4. palpation

Superfisial : supel, massa (-)

Deeper : pain (+) on lower regio abdominal , hepatomegali
(-), Spleenomegali (-) Murphys sign (-)

interpretation : pain on lower regio abdominal

Extremity
Ekstremity

Superior

Inferior

Oedem

-/-

-/-

Cold extremities

-/-

-/-

Physiological Reflect

+/+

+/+

Ikteric

-/-

-/-

Impression

normal

Laboratory Result March 15th, 2014

Examination

Result

Unit

Normal value

Hematology
Hemoglobin

18.5

mg/dl

11,7-15,5

Hematocrit

53.6

33-45

Leukocyte

19.6

Thousand/uL

3,6-11,0

Platelet

231

Thousand/uL

150-440

Blood group/ Rh

B/ positive
Diff

Eosinofil

1-3

Basofil

0.5

0-1

Neutrofil

79

50-70

Limfocyte

16.5

25-40

Monocyt e

3.2

2-8

Chemical
GDS

67

mg/dl

75 100

Uric Acid

12.4

mg/dl

2.6 5.7

Ureum

64

mg/dl

10 50

Creatinin

1.63

mg/dl

0.5 0.9

Total Bilirubin

0.66

mg/dl

0.1 1.0

Bilirubin Direct

0.15

mg/dl

0 0.2

Bilirubin Indirect

0.51

mg/dl

0 0.75

Total Protein

8.50

g/dl

6.0 8.0

Albumin

4.06

g/dl

3.4 4.8

Globulin

4.44

g/dl

SGOT

94

U/l

0 35

SGPT

41

U/l

0 - 35

Natrium

137.2

mmol/L

135 147

Kalium

3.27

mmol/L

3.5 - 5

Chloride

109.4

mmol/L

95 105

Calcium

8.5

mg/dl

8.8 10.8

Magnesium

2.2

mg/dl

1.6 2.4

Cont...
Cholesterol

91

mg/dl

<200

Trigliserid

140

mg/dl

<160

HDL

21

mg/dl

37 92

LDL

31

mg/dl

60 - 130

Imunoserology
HBsAg

Non Reaktif

Non Reaktif

Blood Gas Analyze

FIO2

61.0

pH

7.483

pH (37C)

7.483

pCO2

21.5

mmHg

pCO2 (37C)

21.5

mmHg

pO2

243.7

mmHg

pO2 (37C)

243.7

mmHg

SO2%

99.9

94 98

HCT

36

35 45

Hb

12.1

mmol/L

BE ecf

-7.4

mmol/L

BE b

-4.7

mmol/L

SBC

20.5

mmol/L

7.37 7.45

33 44

71 104

-2 - +3

Cont...
HCO3

16.3

mmol/L

22 29

TCO2

16.9

mmol/L

23 - 27

411.1

mmHg

A-aDO2

167.4

mmHg

a/A

0.6

RI

0.7

V%

O2 Cap

16.8

mL/dL

O2Ct

17.5

mmol/L

Lactate

1.7

mmol/L

Calsium ++

1.08

mmol/L

Interpretation :
Leukositosis
Neutrofilia
Limfopenia
Hipoglikemi
Hiperurisemia
Hipokalemi
Hipokalsemia
Increase SGPT SGOT
azotemia
Asidosis metabolic

EKG

Interpretation
Rhythm
Frequency
Axis
Zona transisi
P wave
PR Interval
QRS complex
ST Segment
- ST elevation
- ST depression
T wave
- T inverted
- T tall
Impression

: Reguler
: 1500/12 kk =125x/min
: NAD ( Normo Axis Deviation )
: V3
: normal 0,08
: normal 0,12
: normal 0,08
::::: Sinus tachycardi

CHEST X-RAY

Interpretation :
Cor
: Normal
Pulmo : Normal

Data Abnormality
Anamnesis
1. Loos of conciouness
2. Diarrhea > 10
times/day
3. Green stool
4. Nausea
5. Vomitus > 5 times
6. Decrease appetite
7. Weak
8. Lower abdominal
pain
9. Hypertension
history
10. Gastritis history

Physic Examination
12. t = 38,3
13. Dry lips
14. Poor turgor skin
15. PF abdomen = pain
on lower regio
abdominal

Advance examination
Lab :
16. Leucocytosis
17. Neutrofilia
18. Limfopenia
19. Hiperurisemia
20. Hipokalemia
21. Azotemia
22. Asidosis metabolic
23. EKG : sinus
tachycardi

infeksi

leukositosis

Diare > 10x,

muntah

dehidrasi

Gangg.
elektrolit

Hipokalemi
Hipercloride
hipokalsemia

Syok hipovolemia

Ureum
creatinin
meningkat

UNCONCIOUSNESS

unconciousness
Asidosis
metabolik
Alkalosis
respiratorik

Kerusakan
hepar
Test fungsi hati
abnormal (HDL
turun)
Gangguan fungsi hepar
(SGOT SGPT
meningkat)

Problem list
1. Se
2. Acute diarrhea with severe dehydration
3. Hipokalemia
4. Hiperurecemia

Unconsiouness
Ass :
Non cerebral

Syok hipovolemia
Sepsis
Gangguan elektrolit

 Intial Plan Diagnosis :

PCR, electrolit test, urin test, kultur darah, kultur
sensitivitas.
Initial Plan Therapy :
- 02 6-10 liter/minutes
- Ceftriaxone
- inf. RL loading dose 2000cc40tpm
- Paracetamol 3x500
Ip. Monitoring :
GCS, vital sign, balance cairan, electrolit, PH darah
IP. Ex :
- Edukasi kepada keluarga mengenai penyakitnya dan
komplikasinya

Acute diarrhea with severe

dehydration

Ass

: diagnosa etiology bacteri: e.coli, salmonella typhi, disentri amobiasis, cholera, travelling
gastroenteritis, food intoxication
complication asidosis metabolic, syok hipovolemic, acute kidney disease

IpDx

: feces routine, stool culture

IpTx

: Rehidration RL, loading dose = 2ooocc 40 tpm

- Ceftriaxone
- Loparamide 2mg 3 x 1

IpMx

: vital sign, fluid balance, dehydration symptom, peristaltic sounds

IpEx

:
Eating small meals and snacks often throughout the day is usually easier to tolerate than eating
large meals two or three times a day.
Drink and eat high-sodium foods, such as broths, soups, sports drinks, crackers, and pretzels. Some
sports drinks can help replace electrolytes lost through persistent diarrhea.
Drink and eat high-potassium foods, such as fruit juices and nectars, potatoes without the skin, and
bananas.
Drink at least 1 cup of liquid after each loose bowel movement.

Hipokalemi
Ass :
IP.Dx : electolit test, EKG
Ip. Tx :
non pharmacology : diet high calium
pharmacology : KSR 3x600 mg
Ip. Mx : electrolit test everyday
Ip. Ex : - diet high calium (banana, avocado,
tomato)
Kebutuhan kalium 4,6

HIPERURISEMIA
Ass :
IP. Dx: uric acid
IP. Tx:
Farmakologis
allupurinol 2x100 mg

IP. Mx:
Lab : uric acid, GFR,
IP. Ex :
Consumption drug regularly
Avoid high purin intake

Kelainan test fungsi hepar

Ass : fatty liver, hepatitis
Initial Plan Diagnosis :
USG abdomen, Biopsi
Intial Plan Therapy :
- curcuma 2x200 mg
Intial Plan Monitoring :
SGPT, SGOT, alkali fosfatase, albumin
Intial Plan Education :
diet low cholesterol

Follow up
15/03/2014

TD

HR

RR

122/70
mmhg

16/03/20 17/03/201
18/03/2014
14
4
130/80
mmhg

120/70
mmhg

110/ 80 mmhg

19/03/2014 20/03/2014 21/03/2014

120/70
mmhg

120/80
mmHg

120/80
mmHg

116
102
88
72 x/minutes 86 x/minutes 76 x/minutes 80 x/minutes
x/minutes x/minutes x/minutes
39 x/
minutes

29 x/
minutes

32 x/
minutes

22 x/ minutes

20 x/
minutes

38,2

37,5

37,3

36,2

36,3

24 x/minutes 22 x/minutes

36,4

36,2

WASSALAMUALAIKUM