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MORNING REPORT August, 30th 2013 PHYSICIANS INCHARGE: IA IB II III : dr. Vina, dr. Dian, dr.

Abu (cardio) : dr. Saras, dr. Herwindo : dr. Vindrya : dr. Shinta O, SpPD

dr. Vina

Female/40yo/W.22 Chief complaint: Fever Patient suffered from high grade fever 6 days before admission, sudden onset decreased if given medicine paracetamol and increased again when effects of the medication end. She also reports gum bleeding yesterday while she is brushing her teeth. There was pain in joint since 5days ago, she complained nausea, vomiting once yesterday contains of residual food, and decreased of appetite in this 5 days, she just ate 2 or 3 times a day (contains of porridge and milk). She also complained right upper quadrant abdominal pain since one week ago, intermittenly, not reliefe with meal. there were no epistaxis and rash in both extremities. There was no complained about headache. The passing urine and passing stool were normal. there was no complained about headache. The passing urine and passing stool were normal. History of past illness: history of allergy: History of family: Social History : Patient have not yet married, she is student in junior high school. Her menstruation period is normal, every month. She lives with her parents. Many neighbours suffered from demam berdarah, and fogging progam had already done.

Physical Examination: GA: moderately ill; GCS 456 BP : 130/90 mmHg PR: 72 bpm RR:18tpm Tax:36.5 Head : an -, icteric -, lymphadenophaty JVP : R+0 cm H2O Chest : Cor : Ictus invisible & palpable at ICS V MCL S LHM: ictus , heart waist + RHM: SL D S1 S2 single, without murmur Pulmo : Symmetric; Stem fremitus D=S, no additional sound on both lung area Abdomen : flat, soefl, BS + normal, LS 8 cm, traube space thympany, murphy sign + Extremity : Warm acral, edema -/-

Laboratory Findings (30/8/2013) Leukocyte : 16.600/mm3 Hb : 16,60g/dl MCV : 89,20 fL MCH : 29,40 pg Hematocrite : 50,40 % Thrombocyte : 19.000mm3 RBS : 142 mg/dl SGOT : 75 U/L SGPT : 68 U/L Ureum : 36,30 mg/dl Creatinine : 0,75 mg/dl Na : 133 K : 3,17 Cl : 119 Ig G anti dengue : positive Ig M anti dengue : positive Bil T/D/I : 0,73/0,34/0,39

Abdominal USG (30/8/2013) Conclusion : cholecystitis acuta Cue & clue Female/40yo/w. 22 Fever day 5 , gum bleeding Pain in joint BP 120/80mmHg HR 76 bpm RR 16 tpm Tax 36,2 C Rumple leed + Trombocyte 27,000 Ig G anti dengue :positive Ig M anti dengue: positive Female/40yo/w. 22 S : Nausea and vomiting O: murphy sign + Abd USG : PL 1. Acute febrile illness day 5 + trombocytop enia IDx 1.1 DHF gr II 1.2 DF 1.3 Chikungun ya fever 1.4 Other arboviral infection PDx CBC/ 24hours PTx PMo Diet HCHP 1700 Vs, subj, kcal/day spontaneus IVFD NaCl bleeding 0.9% 30 dpm Po: Paracetamol 500mg prn

2. Cholecystitis acute

Inj. Metoclopramide 3x10mg iv Inj. Ciprofloxacin 2x400mg iv

VS Subj.

cholecystitis acuta Bil T/D/I: 0,73/0,34/0,39 Female/40yo/w. 22 Fever day 5 , gum bleeding Ig G Ig M anti dengue : positive OT/PT 75/68

3. Transaminiti s

3.1 dt no.1

Treat underlying disease


Condition this morning BP: 130/80 mmhg PR: 76 x/mnt RR: 16 x/mnt Tax: 36,7