DUTY REPORT NOVEMBER 26TH 2013

ASNA,FEMALE, 54 YO ( TP)
Cc : Diarrhea since 3 days ago Present illness history : Diarrhea since 3 days ago, frequency 10 times/day,mucous (+),bloody (-) Nausea and Vomite since 3 day ago, 1times/day,volume 1/2 spoonfull,containt food and drink Fever since 3 days ago, not continue, tremble (-), sweat (-), not fever now Decreased of apetite since 2 days ago Chest pain since 1 day ago, not referred History of eating spicy foods and acidic previously were denied Breathlesness (-), cough (-),chest pain (-) mixturation usuall No Family who suffer from diseases like this History of Hypertension (-)

Physical examination : Consc : CMC BP : 110/80 mmHg weight=50kg HR : 92x/ Tall= 155cm RR : 25x/ IMT= 20 T : 36,6 C Skin : Turgor decreased Eye : Conjuctiva not anemic,sclera not icterus Mouth : Dry lips, Candidiasis (-) Neck : JVP=5-2cmH2O Lung : vesikuler, rales (-/-), Whezzing (-/-) Heart : ictus was palpable 1 finger medial of LMCS RIC V Abdomen: Liver and spleen werent palpable, bowel sound (+) increased Ext : Fisiology reflex :(+)/(+) Normal

LABORATORIUM
Hb : 15,8 gr/dl Leu : 9200/mm3 Ht : 48% Trombosit : 212.000/mm3 Na : 130 mmol/L K : 2,9 mmol/L Cl : 91 mmol/L GDS : 154 mg/dl Ureum : 94 mg/dl Creatinin : 2,4 mg/dl CKMB : 53 u/L DALDIYONO SCORE=2

WD/ -Non stemi anteroseptal - Acute Gastroenteritis coleriform type with mild dehydration - Hypokalemia ec GEA - AKI RIFLE I ec prerenal ec dehydration - Ichemic Myocard anteroseptal

DD/ Acute Gastroenteritis ec Food intolerance

Th : Rest/low Fiber Diet IVFD Ringer lactat 8 hours/kolf Inj. Ondansetron 3x4 mg (IV) KSR 1x1 Clopidogrel 1x 75 mg ISDN 3x5 mg (if chest pain) Cotrimoxazol 2x960mg Drip heparin Fluid Balance

SUGGESTION EXAMINATION
Culture Feces Check ureum,creatin /day CK-MB Ecocardiografi

TONI ARIANTO,MALE, 35 YO , MW 4
Cc : Fever since 6 days ago Present illness history : Fever since 6 days ago,continous, no tremble, no sweat Nausea ang vomite since 6 days ago, frequency 3 times/day, volume glass, contains what eating and drink Pain of joint since 4 days ago Headache since 4 days ago Decreased of apetite since 3 days ago History of gum bleeding and nose bleeding were denied Cough (-),breathlesness (-) History came back from Papua 6 days ago, and patients stay in Papua 1 month

History of hematoma was denied Mixturation and defecation usuall

Physical examination : Consc : CMC BP : 110/70 mmHg HR : 84x/ RR : 20x/ Temperature : 37,8 C Skin : Flushing (+) Rumple leed (+) Eye : conjuctiva anemic (-), sclera icterus (-) Lung : vesiculer, rales (-/-) Heart : ictus was palpable RIC V1 finger medial of LMCS Abdomen: Liver and spleen werent palpable peristaltik Normal Ext : Fisiologis Reflek (+)/(+) N Pathology Reflek (-)/(-) Edem (-)/(-)

Laboratorium Hb Leu Ht Trombosit

: 15,4 gr/dl : 4400/mm3 : 46% : 78.000/mm3

WD : Dengue Fever DD: Idiophatic trombocytopenia purpura

Thy : Rest/ soft diet high calory hight protein IVFD RL 6 hours/ kolf Paracetamol 3 x500 mg Domperidon 3x10 mg Psidii 3x2 tab until trombocyte >100.000/mm3

Suggestion B U F routine Hb,Ht,Platelet /12 hours Liver Function Renal Function Electrolyte IgG,IgM anti dengue