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MORNING REPORT

dr.Herman - IPD

Monday, January 14th 2013
PHYSICIAN IN CHARGE:
I A : dr. Zoraida, dr Camelia, dr Gregg
(cardio)
I B : dr. Suyoso, dr.
II : dr. Andri
III : dr. Laksmi S., Sp.PD
MODERATOR : dr. Supriono, Sp.PD, KGEH

SUMMARY OF DATA BASE
Female/15 yo/Ward 22
Chief complain: fever
Patient suffered fever since 5 days before admission, high grade,
abruptly onset, intermittenly.it was decreased when She took
medicine from primary health care to relieved her fever. But it
raised again in couple of hours. Fever felt for 2 days then in
days 3 and 4 she felt cold. It was also accompanied with body
and head ache. Head ache like throbbing sensation
He also complained of nausea vomiting and epigastric pain since
5 days ago. Vomiting contained of fluid and residual food,
about 5-6x/day volume about 1 glass/vomit. She vomited
every took meal. She had decreased of appetite since then.
She only took 1-2 spoon/meal.
She didn’t defecating for 5 days. There is no complained of
epistaxis, gum bleeding or bruises on skin.

There is no neighbour or family who had been diagnosed Dengue infection. Social history: She is a student. Family history: No family has Dengue infections or any fever recently. But epigastric pain didn’t relived yet.SUMMARY OF DATA BASE - History of past illness: History of medication: she was admitted in PHC for 3 Days and got medication. DM (-). . HT (-) in family.

3 C GCS 456 Conj. epigastric pain +. soefl. bowel sound normal.PHYSICAL EXAMINATION BP : 100/60 mmHg PR : 99 bpm General appearance : looked moderately ill Head RR : 18 tpm Tax : 36.pale : -/Jaundice : -/JVP R+0cm H2O. Rumple Leede +. S2 single with no murmur Pulmo Vesicular sound. lymphnode enlargement - Thorax : Cor Ictus invisible and palpable at MCL ICS V sinistra LHM ~ ictus RHM: SL D S1. shifting dullness - Extremities edema -. liver span 10 cm . no additional sound Abdomen Fatty. ptechieae - 0 .traube’s space tympani. warm acral.

1 20-40 mg/dL Eritrocyte 5.5 MCH 29.67 <1.4-15.2 mg/dL PCV 45.000 142.0/18 .0-5.5 – 5 mmol/L Cl 104 98 – 106 mmol/L Anti dengue Ig M + Ig G + SGOT 380 0-32 mU/dl SGPT 186 0-33 mU/dl 0/0/73.3 3.300/µL RBS 108 70-100 mg/dl Haemoglobine 16.5 x 103µL Creatinine 0.3 38-42% Trombocyte 30.0 % Diff Count (Normal) .Lab Value Leukocyte 6970 (Normal) Lab Value 4.000424.0/11.1 g/dl 80-93 27-31 Ureum 32.000/µL Na 130 136 – 145 mmol/L K 5.80 MCV 79.7 4.5 11.70011.

025 10 x PH 6.URINALYSIS (dipstick) Result Result SG 1.0 Leucocyte - Cylinder 7.4 coccus/stab - .6 Bilirubin - Crystal - Bacteria 32.0 Epithelia 4.22 Nitrite - Hyaline - Protein trace Granular - Glucose - Leukocyte - Erythrocyte - Erythrocyte - 40 x Keton urine trace Eritrosit 2.3 Urobilinogen - Leukocyte 3.

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40” Conclusion : Sinus rhytima with HR 88 bpm . Heart rate 88 bpm Frontal Axis : Normal Horizontal Axis : Normal PR interval : 0.ECG • • • • • • • Sinus rhythm.12” QRS complex : 0.08” QT interval : 0.

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shape N Conclusion: normal CXR . KV enough. S covered by radioopaque imaging • Phrenicocostalis angle D/S sharp • Pulmo D/S: BVP D/S increased • Cor: site N. size 58% in AP position.CXR • AP position. Bone normal • Trachea in the middle • Hemidiaphragm domeshaped. asymmetric. less inspiration • Soft tissue thick.

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• • • • • Condition this morning : GCS 456 BP 110/60 PR 80 bpm RR 20 tpm .

Thank You .