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MORNING

REPORT
Wednesday, April 15 2015
th

PATIENT IDENTITY
Name
: IKBA
MR
:15020478
Age
: 40 y.o
Sex
: Male
Religion : Hindu
Status
: Married
Occupation : Employee
Address : Jl Tk Yeh Ayung no.38
Denpasar
Date of Arrival: 14/04/2015

ANAMNESIS

Chief Complaint : Diarrhea


Patient complained diarrhea since 2 days BATH.
The diarrhea was more than 10 times /day, with
volume glass every defecation. The stool was
watery, yellowish in colour with mucus and blood.
Patient said theres red blood came out with his
faeces since 3 months ago.
Patient also complained abdominal pain since 2
days BATH. Pain was felt like twisting in lower
abdominal region. Pain was felt before he wanted
to defecate.
Patient also complained fever since 1 day BATH &
occured suddenly. Fever was felt all over the body,
but fever was decreasing slowly.
Before diarrhea, patient consumed fish that was
bought in traditional market.

Patient said he felt thirsty all the time and his


appetite was decreased.
History of vomitting was denied.

History of Patient
Medication History
Patient went to General Practitioner 2 days BATH
and got medication Novaflox 500mg, Primodiar,
Zegase, and Oralit. Patient said after taking
those drugs, the symptoms not getting better
and patient still have diarrhea 8-10 times a day.

History of Patient
Past History
History of this complain before was denied. No
history of heart ds, liver ds, renal ds,
hypertension or DM before.
Family History
No family members had same complains as the
patient. No history of heart ds, liver ds, renal ds,
hypertension or DM in family members

Personal & Social History


Patient is an employee. Patient didnt smoke and
drink alcohol.

PHYSICAL EXAMINATION
General appearance
: Moderately ill
Level of consciousness : CM (E4V5M6)
Vital Sign:
BP : 90/60 mmHg
RR : 18 x/min
PR : 68 x/min
Tax
: 36,3C
Height
: 172 cm
Weight : 63 kg
BMI
: 22,71 kg/m2

Eyes : conj. pale (-/-); icterus (-/-);


Rp +/+ isocoric, shrunken eyes
(+/+)
ENT : Tonsils T1/T1; pharyngeal
hyperemia (-); tongue normal; lip
cyanosis (-) lip wet (+)
Neck : JVP PR + 2 cmH2O;
lymph node enlargement (-)

Thorax

: Simetris, retraction (-)

Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II S
LB
: at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : sonor/sonor
Auscultation : Vesikular + / + , Rh -/-, wh -/-

Abdomen :
Inspection
: Distention (-); ascites (-)
Auscultation : Bowel sounds (+)
Percussion
: Tympani
Palpation
: Tenderness on palpation (+);
liver
& spleen not palpable
quick return of turgor (< 2)
Extremities: Warm +/+; edema -/+/+
-/Woman washer hands (-/-), CRT <2

Status Lokalis
Rectal Toucher :
Terdapat massa uk. 2x2 cm bentuk reguler
Spinchter ani menjepit kuat
Mukosa recti licin
Ampulla recti dbn
Tidak terdapat pembesaran prostat
Pada handschoen terdapat darah berwarna merah

Complete Blood Count


Parameter

Result

Unit

Remarks

Reference range

WBC

23,67

103/L

4,5 11,00

47,00 80,00

-Ne

80,9%

19,15

103/L

-Ly

12,1%

2,86

103/L

13,0 40,0

-Mo

4,6%

1,09

103/L

2,00 10,00

-Eo

0,6%

0,15

103/L

0,00 5,00

-Ba

0,10%

0,03

103/L

0,0 0 2,00

RBC

4,31

106/L

4,00 5,20

HGB

13,7

g/dL

12,00 16,00

HCT

38,2

MCV

88,7

fL

80,00 100,00

MCH

31,9

pg

26,00 34,00

MCHC

35,9

g/dL

31,00 36,00

RDW

11,1

%
3

41,00 55,00

11,60 14,90

Blood Chemistry Panel


Parameter

Result

Unit

SGOT

17

U/L

11,00 33,00

SGPT

16

U/L

11,00 50,00

Albumin

2,8

g/dL

BUN

19

mg/dL

mg/dL

98

mg/dL

Natrium (Na)

134

mmol/L

136-145

Kalium (K)

3,3

Mmol/L

3,50-5,10

Creatinine
Random blood
glucose

Remarks

Reference
range

3,40-4,80
10,00 23,00

0,50 1,20
70,00 140,00

ASSESSMENT
Acute Gastro Enteretis e.c Susp.
Bacteria DD/ Viral
Moderate Dehydration
Susp. Hemmoroid Interna Gr 1
Acute Kidney Injury Stage 1 e.c.
prerenal

Planning
Therapy
Hospitalized
Diet 1900 kkal
IVFD NaCl 0,9% 30 tpm
Paracetamol 3x500 mg prn
Doxycyclin 2x100 mg i.o
Asam tranexamat 3x500 mg i.o

PDx

Faecal Examination (Complete Faecal)

Urinalysis

Monitoring
Vital sign
Complaints
BUN-SC @24 hours

THANK YOU

Dehydration Stage
Symptoms

Mild

Moderate

Severe

Mental status

Fully conscious

Irritable,
weakness

Apatis, lethargy,
unconsciousness

Thirsty feeling

Normal

Feeling
thirsty, really
want to drink

Cant drink

HR

Normal

Normal /

Tachycardi, in
severe case can
cause
bradycardi

Quality of HR

Normal

Normal /
decrease

Weak /
unpalpable

Eyes

Normal

Slightly
shrunk

Shrunk

Tears

Normal

Decrease

Wet

Dry

Severe Dry

Good

<2

>2

Normal

Longer

Longer

Lips and tounge


Skin turgor
CRT

Moderate Dehydration
109% x 30 cc / kg BW / days
= 109% x 30 cc / 63 kg / days
= 2.060 cc / days
= 2060 cc / 24 hours = 85 cc in 1 hour

1 cc = 20 drops macro
85 cc x 20 = 1700 dpm in 1 hour
1700/ 60 minutes = 28 dpm = 30 dpm

DALDIYONO SCORE
Item
Thirsty/Vomit

Score

Apatis
Somnolen/Sopor/Koma
BP sistole 60-90

BP sistole 60
PR 120 x/min
RR > 30 x/min
Skin turgor
Facies cholerica (Sunken eyes, sunken
cheeks)
Vox cholerica (hoarse)
Cold extremities
Washer women hand
Cyanosis

/15 x 10% x 63kg x1L

= 3, 78 L