MORNING REPORT

Sunday, 22 January 2012 PHYSICIAN INCHARGE: IA : dr. Aditya, dr. Nanik, dr. Indra IB : dr. Rusydah, dr. Andri II : dr. Hidayat III : dr. Nur samsu, SpPD-KGH Summary of database Male / 51 yo / W 27 Chief complaint : Acute diarrhea Patient suffered acute diarrhea since 2 day before admission, suddenly onset, frequency for about 4 times a day, volume for about 250 ml each diarrhea. 1 day after, she complaint about high grade fever, joint and muscle pain, abruptly and it made her blackout. She diagnosed as hyperthyroid since young (12 yo), at that time she complaint about palpitation, excessive sweating, decrease of body weight, and diarrhea. She routinely controll at endocrinology outpatient clinic and treated with lugol soution 3x5 drop a day but she stopped controlled after married because there isnt complaint. She has 3 children, her husband was die 3 years ago, her menstrual cycle was normal. Physical examination
BP = 80/60 mmHg PR = 118 bpm RR = 22 tpm GCS : 456 Icteric ( - ) Tax : 38.6 C General appearance looked moderatlly ill; Head Neck Thorax cor lung Anemic ( + ) JVP R + 0 cm H2O Ictus invisible, palpable at AAL(S) ICS V S1 S2 single, additional sound ( - ) Simetric, SF D = S, V V V V V V Rh - - Wh - - - ++ - -

Abdomen Extremities

Flat, soufel, bowel sound (+) normal, liver span 8 cm, traube space tympani No abnormality

Laboratory finding
Lab Leucocyte Hemoglobin Value 10,300 8.2 3500-10000/L 11,0-16,5g/dl Lab Na K Value 128 3.05 136-145 Mmol / L 3,5-5,0 Mmol / L

PCV MCV MCH Trombocyte RBS Ureum Creatinine Granulocyte

25.6

35-50% 80-91 26,5-33,5

Cl Ca P Alb PPT APTT SGOT SGPT INR

108

98-106 Mmol / L

69.000 89 30.2 1.11 9,400

150000-390000 (<200)mg/dL 10-50mg/dL 0,7-1,5mg/dL

3.5 5.5 g/dl 18.0 37.7 57 27 1.56 C 11.8 C 28.4 11-41U/L 10-41U/L

CXR
AP position, asymeric, KV too strong, Less inspiration, trachea in the midlle, soft tissue and bone Normal, Phrenico costalis angle on Right and Left sharp, Hemidiaphragm dome shape Lung D/S clear. Lung : Clear Cor : site normal, size CTR 55 % and shape normal Conclusion : normal CXR

ECG
CUE and CLUE Sinus Rhythm, HR 130 x/m Frontal Axis : Normal Horisontal Axis : Counterclock wise PR interval : 0.12 QRS complex : 0.06 QT interval : 0.36 Conclusion : Sinus tachycardia, HR 130 bpm P. List I. Dx 1.1 Grave Disease 1.2 De Quervain thyroid disease 13 Hashimoto thyroiditis P. Dx P. Th/ P. Mo/

female/ 43 YO 1. thyroid Ax: strorm Abdominal pain, diarrhea since 2 days ago, fever since 1 day ago, excessive sweating, diagnosed as thyroid disease since 12 years old and treated with lugol solution 3x 5 drop and stopped sice 20 years ago PE: PR 118 RR 22 Mass at her neck, diffuse, tenderness (-), bruit (-) Rhonkhi at basal area of bilateral lungs Lab : Burch+Wartofsky score 45 Wayne index 18

TSH, Free T3, Bed rest Pulse rate T4 1900 kcal diet per day ECG O2 - 4 lpm n.c Subjective Lugol solution 3x5 drop (po) Inj. Dexamethason 1x2 mg (iv) PO: PTU 3 x 200 mg

Female/43 yo Ax: Diarrhea since 2 days ago, frequency 4 times aday, volume 250 cc, nausea nd vomiting, fever, decrease of apettite PE: BP 80/60 mmHg PR 118 tpm, Shunken eyes Lab : Daldijono score 4 Female/43 yo Ax Dry Cough for 4 days PE Aus : v v v v bv bv Rh: - - + + LAB Leucocyte: 10.300 Granulocyte 9300 PORT score : 73 Female/43 yo Ax : Pale conjunctiva (+) Lab Hb 8.1 MCV 84 MCH 27 Female/43 yo Ax High grade fever since 1 days ago PE T ax 38.6 Pale conjunctiva LAB Hb 8.1 Trombocyte 69,000

2. acute watery diarrhea moderate dehidration

2.1 dt no1 2.2 viral infection 1.3

Plasma Intravenous volume Blood speciic gravity repletion pressure RL Subjective 4x4.5x1 litre complaint 15 1200 ml/2 hours iv drip continous with maintenance 20 dpm (iv) Atapulgite 2 tab/ diarrhea

3. Acute Lung 3.1 Sputum cultur Ceftriaxone 2x1 g (iv) Infection Pneumonia/C and sensitivity skin test AP test

Subjective complaint

4. Anemia normochrom normocytair

3.1related to TIBC no 1 Serum iron 3.2 chronich Bil T/D/I inflamation 3.3 Hemolytic anemia 5.1 Dengue BMP fever 5.2 other arboviral inf. 5.3 MDS 5.4 Aplastic Anemia

Treat underlying disease Recheck Hb Vital sign

5. Bisitopenia

Confirm diagnosed

Serial CBC

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