Morning Shift Report Saturday, 16-11-2013 dr.

Dikara

Physician In Charge: 1A : dr. Dikara, dr. Hesti dr. Fitranti (Cardio) 1B : dr. Herman, dr. Nanik T II : dr. Rifai III : dr. Sri Sunarti, Sp.PD Summary of Data Base Female 60 yo/ w.28 Chief complain : Diarrhea  Patient suffered from diarrhea since one day before admission, frequency about more than 10x/day, watery > residual feces, volume about 1/2 glass of mineral water, without blood (), foam (-) ,but with mucous (+) accompined some times with epigstric pain.  She said about diarrhea, fist diarrhea like “wash rice” and mucous but since today diarrhea watery > residual feces , and persist with mucous.  She did not eat something that different from daily food. She also complained felt thirsty since diarrhea  She have hypertension since 7 month ago, BP about 140/-, but she didn’t took drug because she didn’t felt anything. History of hospitalization before was unknown  History of social living: she is a house wife with 4 children Physical Examination
Ward BP = 130/90 mmHg PR = 88 bpm, regular, strong RR = 18 bpm GCS 456 Icteric sclera (-) Tax : 36,9°C

General appearance looked moderate ill Head Neck Chest Heart: Pale conjunctiva (-) JVP R + 0 cmH2O 30 degree

Ictus invisible and palpable at ICS V MCL S LHM ≈ ictus RHM: SL D S1, S2 single, murmur (-) Symmetric, SF D=S, normal percussion, Rh - - Wh - - - - - Soefl, bowel sound (+) increase, liver span 8 cm, traube’s space thympani, shifting dullness ( - ), epigastric tendenners (+)

Lung:

Abdomen

000 29 30 NORMAL 11.96 110 NORMAL < 200 mg/dl 10-50 mg/dL 0.5-33.0 mmol/L 98-106 mmol/L ECG ( November 16th 2013 )  Sinus rhytm with HR 90 bpm  Frontal Axis : Norml  Horizontal Axis :Normal  PR interval : 0.08”  QT interval : 0.Extremities Leg edema -/. symmetric.16  QRS complex : 0. size: CTR=45% Conclusion: Normal CXR .5 g/dl 80-96 fl 26.5 pg 3.5-5.2/80/ 12.70 236. enough KV.60 1.520 1. enough inspiration Soft tissue and bone: normal Trachea in the middle Sinus phrenicocostalis dextra and sinistra dome sharp Hemidiaphragma dextraand sinistra dome-shape Lung: BVP normal. warm acral Laboratory Findings (November 16th 2013) LAB Hemoglobin MCV MCH Leukocyte Eo/Bas/Neu/Limf /Mon PCV Trombocyte SGOT SGPT VALUE 15.000/µL 0-4/0-1/51-67/2533/2-5 35-50% 150.10 81.0-16.32” Conclusion : Sinus rhytm HR 90 bpm CXR ( November 16th 2013 ) AP position. cardiac waist (+).500-10.6/6.0/0.02 136 3.7-1.90 10.0 42.000-390.000/µL 11-41U/L 10-41U/L RBS Ureum Creatinine Natrium Kalium Chlorida LAB VALUE 86 21..80 28. Cor: site N.5 mg/dL 136-145 mmol/L 3.

28 A History f HT since 7 month ago BP about 150/PE TD: 130/90 N: 88 strong RR: 18 ECG: sinus rhytm 90 bpm PL 1. Acute inflamm atory diarhea with mild dehydra tion IDx 1.9% 20dpm Inf.2 Shigelosis 1. low fiber diet. routinely took drug .02 Daldiyono score: 1 Female/ 60 yo/W.520 Neu: 80.0% Na: 136 K: 3. Metoclopramid 3x10 mg (PRN) IV PO: Ataplugit 2 atblet every diarrhea.5 mgpost poned BP Low salt diet.28 A Diarhea since yesterday >10x/d Nausea Vomiting Residual feces (+) Mucous (+) PE TD: 130/90 N: 88 strong RR: 18 Bowel sound (+) Epigastric tendenerrs (+) At 08:45 PM urination Lab: Leu: 10. Ciprofloxacin 2x400 mg IV Inj.CUE AND CLUE Female/ 60 yo/W. VS. History of HT Fundus copy Low salt diet <2 gr/d PO: Captopril 3x12.96 Cl: 110 Ur: 21.1 EIEC 1. maximal 10 tablet/day PMo S. 2. urine produ ction PEd Higine.60 Cr: 1.3 Salmnelosis PDx Fecal culture and sensitiv ity PTx Low fiber diet 1700kkal/day IVFD NaCl 0.