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MORNING REPORT dr. Vina

August, 30th 2013

PHYSICIANS INCHARGE:

IA : dr. Vina, dr. Dian, dr. Abu (cardio)

IB : dr. Saras, dr. Herwindo

II : dr. Vindrya

III : dr. Shinta O, SpPD

Female/40yo/W.22

Chief complaint: Fever

Patient suffered from high grade fever 6 days before admission, sudden onset decreased if

given medicine paracetamol and increased again when effects of the medication end. She also reports

gum bleeding yesterday while she is brushing her teeth.

There was pain in joint since 5days ago, she complained nausea, vomiting once yesterday

contains of residual food, and decreased of appetite in this 5 days, she just ate 2 or 3 times a day

(contains of porridge and milk). She also complained right upper quadrant abdominal pain since one

week ago, intermittenly, not reliefe with meal.

there were no epistaxis and rash in both extremities. There was no complained about headache. The

passing urine and passing stool were normal.

there was no complained about headache. The passing urine and passing stool were normal.

History of past illness: -

history of allergy: -

History of family: -

Social History : Patient have not yet married, she is student in junior high school. Her

menstruation period is normal, every month. She lives with her parents. Many neighbours suffered

from demam berdarah, and fogging progam had already done.

Physical Examination:

GA: moderately ill; GCS 456

BP : 130/90 mmHg PR: 72 bpm RR:18tpm Tax:36.5Head : an -, icteric -, lymphadenophaty -

JVP : R+0 cm H2O

Chest :

Cor : Ictus invisible & palpable at ICS V MCL S

LHM: ictus , heart waist +

RHM: SL D

S1 S2 single, without murmur

Pulmo : Symmetric; Stem fremitus D=S, no additional sound on both lung area

Abdomen : flat, soefl, BS + normal, LS 8 cm, traube space thympany, murphy sign +

Extremity : Warm acral, edema -/-

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Laboratory Findings (30/8/2013)Leukocyte : 16.600/mm3

Hb : 16,60g/dl

MCV : 89,20 fL

MCH : 29,40 pgHematocrite : 50,40 %

Thrombocyte : 19.000mm3

RBS : 142 mg/dl

SGOT : 75 U/L

SGPT : 68 U/L

Ureum : 36,30 mg/dl

Creatinine : 0,75 mg/dl

Na : 133

K : 3,17

Cl : 119

Ig G anti dengue : positiveIg M anti dengue : positive

Bil T/D/I : 0,73/0,34/0,39

Abdominal USG (30/8/2013)Conclusion : cholecystitis acuta

Cue & clue PL IDx PDx PTx PMo

Female/40yo/w.

22

Fever day 5 ,

gum bleeding

Pain in joint

BP

120/80mmHg

HR 76 bpm

RR 16 tpm

Tax 36,2 C

Rumple leed +

Trombocyte

27,000Ig G anti

dengue :positive

Ig M anti

dengue: positive

1.Acute

febrile illnessday 5 +

trombocytop

enia

1.1 DHF gr

II

1.2 DF

1.3

Chikungun

ya fever

1.4 Other

arboviral

infection

CBC/

24hours

Diet HCHP 1700

kcal/day

IVFD NaCl

0.9% 30 dpm

Po: Paracetamol

500mg prn

Vs, subj,

spontaneus

bleeding

Female/40yo/w.

22

S : Nausea and

vomiting

O: murphy sign

+Abd USG :

2.

Cholecystitis

acute

Inj.

Metoclopramide

3x10mg iv

Inj.

Ciprofloxacin

2x400mg iv

VS

Subj.

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cholecystitis

acuta

Bil T/D/I:

0,73/0,34/0,39

Female/40yo/w.

22Fever day 5 ,

gum bleeding

Ig G Ig M anti

dengue :

positive

OT/PT 75/68

3.

Transaminitis

3.1 dt no.1 Treat underlying

disease

S, VS,

OT/PT

Condition this morning

BP: 130/80 mmhg

PR: 76 x/mnt

RR: 16 x/mntTax: 36,7