MORNING REPORT

dr.Herman - IPD

Monday, January 14th 2013

PHYSICIAN IN CHARGE:
I A : dr. Zoraida, dr Camelia, dr Gregg
(cardio)
I B : dr. Suyoso, dr.
II : dr. Andri
III : dr. Laksmi S., Sp.PD
MODERATOR : dr. Supriono, Sp.PD, KGEH

SUMMARY OF DATA BASE

Female/15 yo/Ward 22
Chief complain: fever
Patient suffered fever since 5 days before admission, high grade,
abruptly onset, intermittenly.it was decreased when She took
medicine from primary health care to relieved her fever. But it
raised again in couple of hours. Fever felt for 2 days then in
days 3 and 4 she felt cold. It was also accompanied with body
and head ache. Head ache like throbbing sensation
He also complained of nausea vomiting and epigastric pain since
5 days ago. Vomiting contained of fluid and residual food,
about 5-6x/day volume about 1 glass/vomit. She vomited
every took meal. She had decreased of appetite since then.
She only took 1-2 spoon/meal.
She didnt defecating for 5 days. There is no complained of
epistaxis, gum bleeding or bruises on skin.

SUMMARY OF DATA BASE

-

History of past illness: History of medication: she was admitted in PHC for 3 Days
and got medication. But epigastric pain didnt relived yet.
Social history: She is a student. There is no neighbour or
family who had been diagnosed Dengue infection.
Family history: No family has Dengue infections or any fever
recently. DM (-), HT (-) in family.

PHYSICAL EXAMINATION
BP : 100/60
mmHg

PR : 99 bpm

General appearance : looked

moderately ill
Head

RR : 18 tpm

Tax : 36.3 C

GCS 456

Conj.pale : -/Jaundice : -/JVP R+0cm H2O, lymphnode enlargement -

Thorax : Cor

Ictus invisible and palpable at MCL ICS V sinistra

LHM ~ ictus RHM: SL D
S1, S2 single with no murmur

Pulmo

Vesicular sound, no additional sound

Abdomen

Fatty, soefl, bowel sound normal, liver span 10 cm

,traubes space tympani, epigastric pain +, shifting
dullness -

Extremities

edema -, warm acral, Rumple Leede +, ptechieae -

Lab

Value

Leukocyte

6970

(Normal)

Lab

Value

4.70011.300/L

RBS

108

70-100 mg/dl

Haemoglobine 16,80
MCV
79,5
MCH
29,5

11,4-15,1 g/dl
80-93
27-31

Ureum

32,1

20-40 mg/dL

Eritrocyte

5,7

4.0-5.5 x
103L

Creatinine

0,67

<1,2 mg/dL

PCV

45,3

38-42%

Trombocyte

30.000

142.000424.000/L

Na

130

136 145
mmol/L

5,3

3,5 5 mmol/L

Cl

104

98 106 mmol/L

Anti
dengue
Ig M

Ig G

SGOT

380

0-32 mU/dl

SGPT

186

0-33 mU/dl

0/0/73,0/18
,0/11,0

Diff Count

(Normal)

URINALYSIS
(dipstick)

Result

Result

SG

1.025

10 x

PH

6.0

Epithelia

4,0

Leucocyte

Cylinder

7,22

Nitrite

Hyaline

Protein

trace

Granular

Glucose

Leukocyte

Erythrocyte

Erythrocyte

40 x
Keton urine

trace

Eritrosit

2,3

Urobilinogen

Leukocyte

3,6

Bilirubin

Crystal

Bacteria

32,4

coccus/stab

ECG

Sinus rhythm, Heart rate 88 bpm

Frontal Axis
: Normal
Horizontal Axis : Normal
PR interval
: 0.12
QRS complex : 0.08
QT interval
: 0.40
Conclusion : Sinus rhytima with HR 88 bpm

CXR
AP position, asymmetric, KV enough, less
inspiration
Soft tissue thick, Bone normal
Trachea in the middle
Hemidiaphragm domeshaped, S covered by
radioopaque imaging
Phrenicocostalis angle D/S sharp
Pulmo D/S: BVP D/S increased
Cor: site N, size 58% in AP position, shape N
Conclusion: normal CXR

Condition this morning :

GCS 456
BP 110/60
PR 80 bpm
RR 20 tpm

Thank You