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 didnt took drug because she didnt 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 : 36,9C

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, traubes space thympani, shifting dullness ( - ), epigastric tendenners (+)

Lung:

Abdomen

Extremities

Leg edema -/- , warm acral

Laboratory Findings (November 16th 2013)

LAB Hemoglobin MCV MCH Leukocyte Eo/Bas/Neu/Limf /Mon PCV Trombocyte SGOT SGPT VALUE 15.10 81.80 28.90 10.520 1.0/0.2/80/ 12.6/6.0 42.70 236.000 29 30 NORMAL 11,0-16,5 g/dl 80-96 fl 26,5-33,5 pg 3.500-10.000/L 0-4/0-1/51-67/2533/2-5 35-50% 150.000-390.000/L 11-41U/L 10-41U/L RBS Ureum Creatinine Natrium Kalium Chlorida LAB VALUE 86 21.60 1.02 136 3.96 110 NORMAL < 200 mg/dl 10-50 mg/dL 0,7-1,5 mg/dL 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L

ECG ( November 16th 2013 ) Sinus rhytm with HR 90 bpm Frontal Axis : Norml Horizontal Axis :Normal PR interval : 0.16 QRS complex : 0,08 QT interval : 0,32 Conclusion : Sinus rhytm HR 90 bpm CXR ( November 16th 2013 )

AP position, symmetric, enough KV, 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, Cor: site N, cardiac waist (+), size: CTR=45% Conclusion: Normal CXR

CUE AND CLUE Female/ 60 yo/W.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: 10.520 Neu: 80.0% Na: 136 K: 3.96 Cl: 110 Ur: 21.60 Cr: 1.02 Daldiyono score: 1 Female/ 60 yo/W.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 1.1 EIEC 1.2 Shigelosis 1.3 Salmnelosis

PDx Fecal culture and sensitiv ity

PTx Low fiber diet 1700kkal/day IVFD NaCl 0.9% 20dpm Inf. Ciprofloxacin 2x400 mg IV Inj. Metoclopramid 3x10 mg (PRN) IV PO: Ataplugit 2 atblet every diarrhea, maximal 10 tablet/day

PMo S, VS, urine produ ction

PEd Higine, low fiber diet.

2. History of HT

Fundus copy

Low salt diet <2 gr/d PO: Captopril 3x12.5 mgpost poned

BP

Low salt diet, routinely took drug