MORNING REPORT

Monday, April 7th, 2014

Mentor :
DR. dr. Abimanyu, Sp.PD, KGEH


Patient Identity
Name : Mr. A
Age : 59 yo
Adress : Gg. Meranti 2 RT.09 Banjarbaru
Religion : Moslem
Occupation : Employee
Summary of Data Base
Chief Complain : BAB cair (heteroanamnesis)
Pasien mengeluhkan BAB cair sejak 3 hari yang lalu dan
muncul secara mendadak. Frekuensi BAB 3 kali per hari
dengan konsistensi cair berwarna kuning berlendir. Pasien juga
mengeluhkan sakit perut, dan lemas.

RPD: Keluhan serupa(-), HT (-), DM (-)
RPK: HT (-), DM (-)
BP = 90/60 mmHg Pulse rate = 120
bpm
Regular, weak
RR = 32 tpm

Tax : 36,0 C
General appearance looked Moderate ill GCS 456
Head Pale conjungtiva (+) Icteric (-)
Neck JVP= R + 2 cm H2O
Thorax: Cor: Inspectio : Iktus cordis unseen
Percusion: upper cor : ICS II Linea Parasternalis
Dextra/Sinistra
Below cor : ICS V Linea Parasternalis D, ICS V LMC
S
Palpation : Iktus Cordis palpable at ICS V LMC S
Auskultation : S1, S2 single, murmur (-), gallop (-)
Lung: Symmetric, S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen BU (+) meningkat
Abd. Pain + + +
+ + +
+ + +
Extremities Normal
Laboratorium (6 April 2014)
Examination Result Normal value
hemoglobin 11.9 12.00-16.00 g/dl
Leucosit 18.1 4.0-10.5 Ribu/ul
eritrosit 4.89 3.90-5.50 juta/ul
hematocrit 36.1 37.00-47.00 Vol%
trombocit 352 150-450 Ribu/ul
RDW-CV 14.7 11.5-14.7 %
MCV 74.0 80.0-97.0 Fl
MCH 24.3 27.0-32.0 Pg
MCHC 32.9 32.0-38.0 %
Gran% 68.5 50.0-70.0 %
Limfosit% 15.8 25.0-40.0 %
Mid% 15.7 4.0-11.0 %
Gran# 12.40 2.50-7.00 Ribu/ul
Limfosit# 2.9 1.25-4.0 Ribu/ul
Mid# 2.8 Ribu/ul
GDS 120 <200 Mg/dl
SGOT 29 0-46 u/l
SGPT 19 0-45 u/l
Ureum 22 10-50 Mg/dl
creatinin 0.9 0.6-1.2 Mg/dl
Natrium 128.8 135-146 Mmol/l
Kalium 3.2 3.4-5.4 Mmol/l
Chlorida 88.2 95-100 Mmol/l
CUE AND CLUE Problem
List
IDx PDx PTx PMo
Mr. A/59 yo
A
BAB cair > 3x/hari
Nyeri perut

PE :
BU (+) meningkat



GEA GEA

DR
FL

Terapi dari IGD
IVFD RL drip
neurobion 5000 20
tpm
Inj. Ranitidin 2x1
Inj. Ondansentron
2x1
Inj. Ceftriaxone 3x1 g
Inj. OMZ 2x1

Terapi Ruangan
Bed rest
Guyur RL 1 kolf
Jika KU
membaik, RL 20
tpm
Inj. Ranitidin 2x1
Inj. Ondansentron
(k/p)
Inj. Ceftriaxone 2x1 g
Inj. OMZ (stop)
PO. Lodia 3x2 tab
(bila mencret)
Subjective

Vital sign



POMR