MORNING REPORT

Thursday, July 28th 2016

Co-Ass in Charge :
Intan Kautsarani
Nancy Bria

Supervisor :
dr. Dewi Indiastri, SpPD
 SUMMARY OF DATA BASE
Mr. M /24 yo/ Ward 27

HISTORY TAKING : autoanamnesis

CHIEF COMPLAINT : Diarrhea

HISTORY OF PRESENT ILLNESS :

Patient suffered from diarrhea since 5 days ago. The diarrhea >5x/day contain liquid, without
mucous and some times contain fresh blood (streak), but sometimes balck. Around a half of
aqua glass.

He also suffered from fever since 5 days ago, high and sudden. He took paracetamol, but the
fever never decreased.

There is intermittent oral thrush and white plaque since 2 months ago. No fever found.

He has watery diarrhea since 2 weeks ago, 4 times a day without bleeding. At the primary care,
he was given some medications and got better. 2 days later, he had diarrhea again. Then his
body became weak, especially the legs.

There are decrease body weight about 3 kg since 2 months ago. He said that he is getting
thinner. The appetite also decreased since 1 last month because of nausea. He just ate a little
portion than daily meals.
 Patient also complaint about fever in this 4 days. The fever was
abruptly onset. It was accompanied by red spotted in upper and lower
extremities. Sometimes he felt itchy about red spotted in the skin. The fever
often come and dissapeared for several days.

Social history :
patient has not married yet, history of unsafe multipartner sexual intercourse
(+). Risk factor: Intra venous drug user IVDU (-), tattoo (-),
He had not work yet, he was student of college at unevristy

Past Medical History :

Control at out patient clinic at tropical medicine division, RSSA.

treatment history :
He had been diagnosed HIV and receive drugs called ARV since two years ago
from RSSA.
 Physical Examination
General Appearance: looked moderately ill Looked underweight

GCS: 456 RR = 32 tpm

BP : 100/60 mmHg HR : 58 bpm regular Tax 38 C
regular

Head Anemic conjunctiva (+/+) , icteric sclerae (-) pupil isocor, whitish plaque in mouth
Neck JVP: R + 0 cm H2O in 30 position ; lymph node enlargement (-)
Wall Chest expansion symmetric.
Ictus visible at ICS V MCL S, palpable at ICS V MCL S
Chest RHM ~ SL D
Heart
LHM ~ ictus
S1 and S2 single, murmur (-)
Stem Fremitus N N percussion S S auscultaion v v Rh - - Wh - -
Lung NN SS vv - - - -
NN SS vv + - - -
Flat, soefl, increased bowel sound (+), shifting dullness (-), liver span 8cm, traubes
Abdomen
space tympani, epigastric tenderness (-)
Warm, edema -/-
Extremities -/- , Red spotted (makula papullar) rash in upper and lower
extremities
Urine
30cc/hour
output
 Laboratory finding (08-8-2016)
Lab Value Lab Value
Hemoglobine 10,4 11.4-15.1 g/dl RBS 100 <200 mg/dL
Erithrocyte 3,31 4,0-5,5 Ureum 34,20 10-50 mg/dL
Leukocyte 3,08 3,500-10,300/L
Trombocyte 194 100,000- Creatinine 1,06 <1,2 mg/dL
390,000/L
MCV 88,2 80 - 97 fL
MCH 31,4 26.5 33.5 pg SGOT 133 0 40 U/L
MCHC 35,6 32 36 g/dL SGPT 100 0 41 U/L
Albumin 2,86 3.5 5.5 g/dL
RDW 13,3 11.5 14.5 % Natrium 11012 136-145 mmol/L
2
Diff count 0/0,3/61, 0-4/0-1/51- Kalium 4,34,2 3.5-5.0 mmol/L
7/24,7/13 67/25-33/2-5 % 6
,3
PPT 9,8 9.3 11.4 s Chlorida 8595 98-106 mmol/L
APTT 38 24.5 30.6 s
CD4 (29-06) 110 637-1485
 Blood gas analysis
Parameter Value Normal value
pH 7,49 7,35-7,45
pCO2 17,9mmJHg 35-45
pO2 148,2 mmHg 80-100
Bikarbonat(HCO3) 13,8 mmol/L 21-28
Kelebihan basa (BE) -9,7 mmol/L (-3) (+3)
Sat O2 99,1%(with NC 3lpm) >95%
Hb 12,6

Conclusion : alkalosis respiratorik partially compensated

acidosis metabolic
ECG (August 9 th 2016)
 ECG INTERPRETATION
Sinus bradikardia Heart rate 50 bpm
Frontal Axis :N
Horizontal Axis :Counter Clock wise rotation
PR interval : 0,12
QRS complex : 0,08
QT interval : 0,32

Conclusion : Sinus takikardia Heart rate 125 bpm

CXR 8th Agustus, 2016
CXR

AP position, asymmetric, enough KV, less inspiration

Soft tissue normal, bone normal
Trachea in the middle
Right and left hemidiaphragm were dome shape
Costo phrenico angle D were dull covered by radioopaque
shadow, sinistra were sharp
Right and left lung: normal bronchovesicular pattern
Cor: site normal, size 46% apex embedded, cardiac waist (+)

Conclusion : Dextra Pleural Efusion

 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years old/ 1. Acute 1.1 ETEC Fecal analysis Soft diet 1700kcal/day, Subjective
w.27 Inflamatory 1.2 EIEC Low fiber diet Vital sign
Ax : diarrhea Diarrhea
Intermitten diarrhea Positive fluid balance Urine
since 5 day ago no 250-500cc/24 hours production
mucous, with blood Fluid
The stool consistancy Fluid replacemnent NaCl balance
dominant liquid than 0.9% 2.000 cc loading in 2
soft consistency. hours, continued with
Diarrhea with frequency NaCl 0.9% 1.500cc/24
>3x/day, about 100cc hours ~ 20 tpm
each
Inj
PF: Ciprofloxacin 2x400mg iv
Abdomen : soefl , flat PO:
(+) increased of bowel Attapulgite 2 tab (when
sound diarrhea). Maximal 10
Urine production tablet/day
30cc/hour

Lab:
WBC :
3080/L
Diff Count :
0/0,3/61,7/24,7/13,3
Limfosit count 760
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years 2.Shortness 2.1 PCP LDH, BGA Confirm diagnose Subjectiv
old/ w.27 of Breath 2.2 Lung LED O2 8-10 lpm via e
Ax : TB FBA NRBM Vital sign
Chronic cough 2 2.3 Pleural staining, and BGA
months Effusion culture PO:
Decreased body media LJ N-Acetyl Cystein
weight 2kgBW in Sputum 3x250mg
last 2month culture, gram Cotrimoxazole
Diagnosed HIV sensitivity 1x960
since 2 years ago test
PF:
GCS:456
BP: 100/70 mmHg
PR:100 bpm
RR:32 tpm
Tax:38 C
RH (-/-)
Lab:
BGA : acidosis
metabolic fully
compensated
SGOT : 130 U/L
SGPT : 100 U/L
CXR: Pleural
Effusion D
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years old/ 3. HIV stage Diet HCHP Subjective
w.27 III on ARV 2000kcal/day, low fiber Vital sign
Ax : HBsAg
Chronic cough 2 PO: Anti HCV
months Cotrimoxazole IgM-IgG
Decreased body 1x960mg anti CMV.
weight 2kgBW in last Nystatin drop 4x3cc Ig G Ig M
2month
Oral trush (+) ARV FDC (lamivudin, Toxoplas
Watery diarrhea (+) tenofovir, efavirenz) ma
History of unsafe 1x1 tab VDRL-
multipartners sexual TPHA
Odinofagia CD4

PF:
Oral trush (+)

Lab:
WBC :
3080/L
Diff Count :
0/0,3/61,7/24,7/13,3
Lymphocyte count :
760,76
Determinant HIV :
reactive

CXR: Pleural efusion

D
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years old/ 4. Increased 4.1 HBSAg, anti Confirmed diagnosis Subjective
w.27 of Hepatitis HCV, Avoid hepatotoxicity Vital sign
Ax : transamina viral drugs SGOT/SG
Chronic cough 2 se infection PT
months
Decreased body
weight 2kgBW in last
2month
Consume TB drugs
FDC 1 week
No history of sakit
kuning
PF:
Liver span 10 cm,
abdominal tenderness
(-)
Lab:
SGOT : 133 U/L
SGPT : 100 U/L
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years 5. Oral KOH swab Nystatin drop Subjective
old/ w.27 candidiasis 4x10.000IU Vital sign
Ax : dt no.2
Oral trush (+)
Difficult to swallow
Loose appetite
Odinofagia

PF:
Oral trush in his
tongue

Lab:
WBC :
3080/L
Determinant HIV :
reactive
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years 7. Hyponatr 7.1. dt. Rehydration : Subjectiv
old/ w.27 emia Volume normal saline 20 e
Ax : Hypoosm depletion cc/kg/hour (2 liters Vital sign
Watery diarrhea 3 olar in 2 hours) at ER SE
times yesterday, no Hypovole continue IVFD NS 4hours
mucous, no blood mia 20 dpm post
History of recurrent correction
watery diarrhea in
this one year

Physical
examination
Urine production
30cc/hour

Lab:
Na : 110 mmol/L
OSM : 231,2
mOsm/kg
 CUE AND CLUE PL Idx PDx PTx Pmo
Mr. D / 24 years 8. Hypoalbu 8.1 Treat underlying Subjectiv
old/ w.27 minemia Hypercata disease e
Ax : bolic state Diet extra protein Vital sign
Loose appetite 8.2 Low (white egss, extract Albumin
Decreased body intake snake fish) level
weight 2kg in last
2month
Productive cough 2
months

PF:
Looked
underweight

Lab:
Albumin : 2.86 g/dL
THANK YOU