Morning Report Friday, July 8th 2011

IA : dr. Mecy, dr. Rusyda, dr.Supono IB : dr. Amel, dr. Vindrya II : dr. Maya III: dr. Sri Sunarti, SpPD

SUMMARY OF DATA BASE

Male/Toni, yo/W27 Chief complaint : Fever He had fever with abruptly onset since 1 week ago, fever intermittently, and felt chilling too. He live in Kalimantan for 3 years and since 1 week ago he come back to Malang to visit his parents. He said about 2 months ago, he had malaria vivax. He felt headache since 1 week , but not felt nausea, vomiting and diarhea.

General appearance Blood Pressure

Looked moderately ill GCS : 4 5 6 Physical Examination 110/70

Pulse Rate
Respiration rate T ax Head Neck Chest Heart

66 bpm, reguler
20 tpm 36,5 0C Anemic (-), Icteric (-) JVP R + 3 cmH2O at 45 0 Ictus invisible, palpable ICS V MCL S RHM SL (D), LHMIctus S1 S2 single , murmur Symetric SF D=S , V V V V V V Rh - --Wh - --S/S S/S S/S

Lung

Abdomen Extremities

Slight distended, BS (+) N, Liver span 12 cm, unpalpable, traube space dullness Edema - / -

Laboratory finding
Leucocyte Hemoglobine PCV Trombocyte RBS 5800 9.9 /l gr/dl

Value
N: 3.500 10.000 N: 11,0 16,5

28
22.000 35.6 0.62 22 20 137 3.56 107 Plasmodiu m Vivax

%
/L mg/dl mg/dL mg/dL

35 - 50
150.000 390.000 < 200 10-50 0,7 1,5 11 41 10 41 3,5 5,5 136 145 3,5 5,0 98 106

Ureum
Creatinine SGOT

U/L
U/L g/dl Mmol / L Mmol / L Mmol / L

SGPT
Albumine Na K Cl Blood Maal

CHEST X RAY
AP position, symetric, KV enough, less inspiration, trachea in the middle, soft tissue and bone normal. Phrenico costalis angle D sharp and S covered by cardiac shadow, Hemidiaphragm D dome shaped and S covered by cardiac shadow,. Increase of BV pattern on Lung D/S. Cor site N, CTR 50%. Conclusion : CXR normal

CUE AND CLUE male/ 35 yo Fever 1 week Chilling Headache PE: liverspan 12 cm, traube space dullness(schufn er 2) Lab: plasmodium Vivax, Trombosit: 22.000

PROBLE MLIST

INITIAL DIAGNOSE

PLANING DIAGNOSE

PANING THERAPY

PLANING MONITORING

1. Malaria ( Plasmodiu m Vivax )

Primaquin 1x1 tab Arteesdiakuinamodiakuin 1x8 tab Paracetamol 3x500mg

VS Parasit Count