MORNING CASE REPORT

January 7th, 2015

PATIENT IDENTITY

Initial : IKS
Sex
: Male
Age
: 29 years old
Religion
: Hindu
Natilonality : Indonesian
Marital Status
: Married
Adress : Kerobokan Kelod, Kuta
Time of Arrival : 18.30

ANAMNESIS
Chief Complaint: Watery Stool
Patient came to RSUP Sanglah with chief
complaint of watery stool since 2 days BATH. He
could back and forth to the toilet more than 10
times in one day to defecate. The stool was
yellow and composed mostly of water, few or
without dregs, without mucus and blood.
Abdominal cramps before defecate and burn
sensation while defecate denied.
He also complaint of fever since 2 days
simultaneously with the diarrhea. The fever was
suddenly high, unmeasure and subside with
antipiretic. The history of shivering denied by
patient.

ANAMNESIS
Patient also complaint about nausea and vomiting
since 1 day BATH. He vomited 3 times composed of
water with each volume 60 ml.
He lost appetite since yesterday but not really feel
thirsty. He ate only 2-3 spoon of porridge and drank
1-2 glass of water in 1 day.
He complaint about dizzines and body weakness
since morning. He only wake up to the bathroom for
defecate and urinate. All day he will stay on the bed
and sleep.
Last urination at 14.00 , little, yellowish and no pain.

Past and Drug History

He experienced the same complaint about 3
months before. But the complaint has
stopped after 1 day without drug
consumption.
Patient has come to general practioner
yesterday and given paracetamol, tetracyclin
and metoclopramid. But there is no
improvement so he decided to come to RSUP
Sanglah.
Food recall before he got diarrhea : instant
noodle.

Family History
None of his family have the same complain.
Other systemic disease in family like HT,
diabetes, asthma, heart disease denied.

Social Economy History

Patient was a private employee.
He has habit of drinks coffee 2-3 times
daily.
Awareness of clean and healthy

PHYSICAL EXAMINATION
Present Status:

General condition: Moderately ill

Consciousness
: E4V5M6
BP : 90/60 mmHg
Pulse rate
: 120 bpm
Resp. rate : 22 tpm
Axillary temp.
: 38,1o C
Weight : 90 kg
Height : 180 cm
BMI
: 29,34kg/m2

PHYSICAL EXAMINATION
General Status
Eye
: sunken eyes -/-, anemic -/-, ikt -/-, pupillary reflexes
+/+ isokor, edema palpebra -/ ENT
:
Ear
: Within normal limit
Nose
: Within normal limit
Throat : Tonsil T1/T1, Faring Hiperemis (-) Lip: dry, sticky
Neck
: JVP PR +0 cm H2O, Lymph Node Enlargment (-)
Thorax : symmetrical
Cor : I : ictus cordis unseen
Pal : ictus cordis unpalpable
Per : UB : ICS II
RB : PSL D ICS V
LB : MCL S ICS V
Aus : S1S2 Single, Regular, Murmur (-)

PHYSICAL EXAMINATION
Lung:

I
Pa
Per
Aus
Abdomen : Ins
Aus
Pal
Skin

: Symetrical (static & dynamic)

: VF N/N
: Sonor / Sonor
: Ves +/+ Wh -/- Rh -/: Distention (-)
: Bowel sound (+) increase
: Tenderness (-) Liver/spleen unpalpable,

Turgor Normal
Per
: Tympany (+)
Extremeties : Warm +/+, CRT < 2 seconds, Washer hands -/-,
Edema -/-

LABORATORIES

Complete Blood Count

Parame
ter

Result

Unit

Reference
Range

33,55

103/L

4,1 10,9

WBC
-Ne

30,37

90,5%

103/L

2,5 7,5

-Ly

1,01

3,0%

103/L

1,0 4,0

-Mo

1,17

3,5%

103/L

0,1 1,2

-Eo

0,50

0,10%

103/L

0,0 0,5

-Ba

0,05

0,1%

103/L

0,0 0,1

RBC

6,49

106/L

4,00 5,20

HGB

17,3

g/dL

12,00 16,00

HCT

52,1

36,0 46,0

MCV

80,2

fL

80,0 100,0

MCH

26,6

pg

26,0 34,0

MCHC

33,1

g/dL

31,0 36,0

LABORATORIES

Blood Chemistry Panel

Result

Unit

Remarks

Reference
Range

24

mg/dL

10,00 23,00

Creatinine

1,83

mg/dL

0,50 1,20

Na

127

mmol/L

136-145

3,63

mmol/L

Parameter
BUN

3,5-5,1

LABORATORIES

Feses Lengkap
Parameter

Result

Reference Range

FESES LENGKAP
(FL)
Makroskopis
Warna

Coklat

Darah

Negatif

Konsistensi

Slem

Lendir

Positif

Mikroskopis
Eritrosit

2-3 / lp

Lekosit

Banyak

Amoeba
Kistal

Telor cacing

Lain-lain

<3/ lp

ASSESSMENT
- Gastroenteritis Acute ec bacterial
- Moderate Dehydration
- Sepsis

- AKI Stadium I ec prerenal

THERAPHY
Hospitalized
Loading RL 1800 within 2 hours RL 40
dpm
Paracetamol 3 x 500 mg (PO)
Ciprofloxacin 2 x 200 mg (IV)

PLANNING DIAGNOSIS
- UL
- USG Urology
- BOF

MONITORING

Vital sign
Complaints
Fluid Balance
BUN, SC @ 24 hours

THANK YOU