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MORNING REPORT

COASs IN CHARGE:

Geo Bertha Fernanda
Nur Alfi Dinari

MODERATOR : dr.Laksmi S., Sp.PD

SUMMARY OF DATA BASE
Female/19 yo/W.28
Chief complaint: Dysfagia
Patient suffered from dysfagia since 2 days ago, patient also suffered from
moderate grade fever since 3 days ago, abruptly onset, and subsided when he took
paracetamol but after 6 hours the fever was rising again.
Patien never suffered like this before. She got paracetamol tablet but her complaint
did not relieved. She went to PHC, and then from phc patient refered to Laboratory of
Microbiology FKUB for throat swab.


Patien had completed history of imunisation when she
was child. There wasnt history of contact with his neighbours
or her friends , who suffered from diphteria infection. But in
the area who the patient live, there was 2 patients have
diphteria.

History of past illness:
Same complaint (-)

Social occupation:

PHYSICAL EXAMINATION
BP : 110/70 mmHg PR : 96 bpm reguler,
strong
RR : 22 tpm

Tax : 36,4
0
C
General appearance : looked moderately ill
Looked normoweight
GCS 456 BW: 45 kgs
Head Pale conj. (-) sclera ict (-)
Neck JVP R+0 cm H2O
Thorax : Cor Ictus invisible and palpable at ICS V MCL S
LHM ~ ICS V MCL S, heart waist+
RHM: SL D
S1, S2 single with no murmur
Pulmo Symmetric, SF D=S
Abdomen bowel sound N, liver span 8 cm, traubes space tympani (+)
Extremities Edema (-) , warm acral

Culture result from throat swab
Positive Clostridium diphtheriae
(from Morfologic)
LABORATORY FINDING
:

Result
Normal Value
Leucocyte 5,95 /l 3.500 10.000
Hemoglobine 12,90 gr/dl 11.0 16.5
MCV 81.90 Mm
3
80-93 fL
MCH 27.50 Pg 27-31 fL
Eos/bas/neu/lim/mo 0/0,3/70,9/20
,7/8,1
PCV 38,40 % 35 50
Trombocyte 162.000 /L 150.000 390.000
RBS 77 mg/dl < 200
Ureum 17,40 mg/dL 10-50
Creatinine 0,55 mg/dL 0.7 1.5
SGOT 13 U/L 11 41
SGPT 7 U/L 10 41
Na 135 mmol / L 136 145
K 3,56 mmol / L 3.5 5.0
Cl 107 mmol / L 98 106

ECG (April 25
th
2013)
Sinus rhythm, Heart rate 85 bpm
Frontal Axis : normal
Horizontal Axis : normal
PR interval : 0.12
QRS complex : 0.08
QT interval : 0.36
Conclusion: sinus rhythm with heart rate 97 bpm

CXR (April 24
th
2013)
AP position, symmetric, enough KV, less inspiration
Soft tissue thin, Bone normal
Trachea in the middlle
Hemidiaphragm D/S dome shape
Phrenico costalis angle D/S sharp
Pulmo D/S :normal
Cor: site N, size CTR 50%

Conclusion : normal cxr


CUE AND CLUE PL IDx PDx PTx PMo
Female/22 yo
Ax:
-moderare fever for 3days ,
abruptly onset
- dysfagia
-Her neighbour has been
suffering from diptherie
PE:
Pseudomembran in tonsil
sinistra
BP:110/70 ,
HR: 96
RR:22
T ax :36,4
Lab
Trombosit :162.000

Throat swab culture:
Positive Clostridium
diphtheriae (from
Morfologic)





1. Acute
Tonsilitis
1.1 dt Diphterie
1.2 dt streptococal
1.3 dt infection
mononucleosis
-Throat swab
culture and
sensitivity
-Antibiotic
-CBC/24 hour
and ESR
-Elec Test
-UL
-Soft Diet HCHP 2100 kcal/day
-NACL 0,9 % 20 dpm
Inj PPC 2x1,500.000
Inj ADS 20.000 IM

Po. parasetamol 3 x 500 mg
Surface cooling
Vs
Subj

Urine
producti
on
Intake
Condition this morning
GCS 456
Subjective: fever subsided
BP: 110/70 mmHg
HR: 92 bpm
RR: 20 tpm

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