July 18th 2013- D18
Name : Mrs.08
.S Age : 50 years old Address : SunanGiri.RM : 19.81.
urine remain unremarkbale
. weight loss (-). blood (-). headeache (+) and with symptoms of dry cough since 1 months before hospitalized accompanied with intermittent fever and breathless and sometimes Coughing up blood (+). waste (+). vomiting (+).Chief of Complaint Present illnes
: Diarhea :
– Patient. female 50 years old. with diarhea from three days ago and diarhea 7th times in one day. SHe lost his appetite (+). Nausea (+). cold sweating (-).
DM (-) HT (-).History or pass illness : Gastritis +. TB Pulmo (+) treatment for 6 months History of family :History of sociality : – Herbal Medicine (-)
General status – GCS : 456 Vital Sign: – BP : 127/86 mmHg – Pulse : 132x/mnt – Temp : 380C – RR : 18/mnt Head/neck – An -. Supple. cy-. dys-. retraction (-). Thorax – Symmetric. rh +/-. gallop (-) – ves/ves. wh -/Abdomen – Flat. Tymphani. murmur (-). sonor. red. Extremity – Warm. dry. ict-. Bowel sound (+) increase. Hepar Lien unpalpable. oedema (-)
6 mmol/L : 130 mmol/L
.200 : 298.2 % : 11.7 mg/dl : 9.000 : 15/12 : 96 mol/L : 3.Laboratory Findings
Diff count Hematocrite Hb Leukocytes Trombosite SGOT/SGPT Clorida Serum Calium Serum Natrium Serum : 2/2/80/9/7 : 34.
Clue and Cue
• • • • • • Female. 50 yo Diarhea Nausea Vomiting cough Loss of appetite
Patient. waste (+). female 50 years old. sometimes Coughing up blood (+). headeache (+) and patients present with symptoms of dry cough since 1 months before hospitalized accompanied with intermittent fever and breathless.rh +/-
. 7th times in one day. Chest discomfort (+). mucus (+) Nausea (+). with diarhea from three days ago and diarhea. vomiting (+). blood (-).
Diarhea fever Vomiting Cough > 1 months Loss of appettite
GEA TB pulmo
Cultur feces Sputum
• IVFD RL loading 500cc maintenance 1500cc/24 hours • Inj.Ranitidine 2x 25mg • Consul internist
. Metamizole 3x1 • Inj. Ondancentrone 1 amp • Inj.
Vital signs Complaint
Dubia ad bonam
Explaine to the family about the disease of the family. and also about complication and prognosis.
. about its theraphy and intervention will be done.