Morning report

Thursday, November 24th, 2010

PHYSICIANS INCHARGE:
IA : dr. Nicholas dr. Rusyda
IB : dr. Eric, dr. Rudi
II : dr. Hani
III : dr. Sri Sunarti, SpPD
MODERATOR: dr. Budi Darmawan, Sp.PD-KHOM
 Summary of database
Female/24 yo/W.22
Chief complain: fever
Patient suddenly had a high grade fever since yesterday,
continuously. Fever was accompanied with headache, pain all
over his body.
Patient felt nausea, and vomit 1 time which contained
yellowish liquid, so she lose her appetite. She did not eat at all
since yesterday. She felt weak.
There was no sign of spontaneous bleeding.
 Physical examination
BP = PR = RR = Tax : 39,2 C
110/80 mmHg 120 bpm 20 tpm

General appearance looked moderately ill GCS 456, looked normoweight

Head Anemic - Icteric -

Neck JVP R + 0 cm; 30

Thorax: Cor: Ictus invisible and palpable at MCL ICS V Sinistra

RHM SL Dextra
LHM ictus
S1, S2 single with no murmur

Lung: Symmetric, SF D = S, s s v v Rh - - Wh - -
ss vv -- --
ss vv -- --

Abdomen Flat, soft, liver span 10 cm, troube space tympani

Extremities Warm, ptechiae -,rumple leed test +

 Laboratory findings
Lab Value Lab Value

Leukocyte 9.100- 3.500-10.000/L Ureum 39,2 10-50 mg/dL

4.200
PCV 36,0-34,7 35-50% Creatinine 0,92 0,7-1,5 mg/dL
Hb 12,2-11,6 11,0-16,5gr/dL
Trombocyte 142.000- 150.000- RBS 57-127
121.000 390.000/L Na 129-132
SGOT 27 11-41U/L K 3,63-3,61
SGPT 17 10-41U/L Cl 103-108
 CUE AND CLUE PL IDx PDx PTx PMo
Female/24 yo 1. AFI + 1.1.Dengue Dengue Bed rest Subjective
Fever, acute, high grade, bisitopeni fever NS1 Free diet BP
continuously since a 1.2. Weil- Surface cooling HR
yesterday Chikunguny Felix IVFD RL 30 dpm RR
Cephalgia a Tax
Myalgia and arthralgia 1.2.Other
Tax: 39,2 C Arboviral
BP: 110/80 infection
PR: 120 1.3.Ricketsi
RR: 20 osis
L: 9.100-4.200
Tr: 142.000-121.000
Rumple Leed test +

Female/24 yo 2.Dyspeps 2.1.due to Metoclopramide 3x10 mg Subjective

Nausea and vomiting ia No.1 (iv)
Lose appetite syndrome
Not eat at all for 1 day
Female/24 yo 3.Hypogly 3.1.due to D40% 50 mL (iv) RBS
RBS: 57 cemia No.2