1

Morning Report
Thursday, May, 17th 2012
Moderator :
Physician In Charge:
IA : dr. Eva, dr.Satria, dr.Galuh (Cardio)
IB : dr. Asri, Dyah
II : dr. Endah
III : dr. Laksmi, Sp.PD
Summary Of Database:
Mr. Bukhori/male /45 Y.O/W 27
Chief Complaint : Fever
The patient suffered from high grade fever since 6 days before admission, continuously, sometimes
subsided by paracetamol (panadol) but never reached the normal temperature. This complaint was
accompanied with headache, muscle and joint pain, nausea, decreased of appetite, and gum bleeding
while brushing teeth.
History of HT (+) recently known since one week ago when the patient controlled to PHC near his house
(BP 140/ mmHg).
History of smoking (+) since little until 6 days ago, 12 bars per day.
History of traveling to endemic area (-).
History of previous hospitalization (+): at 2008 (RSSA, ward 25): with the chief complaint: general
yellowish of the body and eye, tea like colored urine, and general swelling.
Physical Examination
BP=140/70
PR= 92 bpm,
RR = 22 tpm
Ax. Temp.=39.8
0
mmHg
regular
C
General App.: looked moderately
GCS : 456
ill
Looked normoweight
Head
Anemic conjunctiva
Icteric sclerae
CI (+), PCI (+)
(-)
(-)
ODS
Neck
JVP : R + 0 cm H2O; Flat
Thorax
Cor
Ictus visible, palpable at fifth ICS, 2 cm lat
from MCL S
RHM SL Dextra ; LHM ictus
S1, S2 single, no murmur
Pulmo
Symmetric; SF D=S; S| S
V|V
Rh
-| Wh - | S| S
V|V
-| +
-|S| S
V|V
-| +
-|Abdomen

Loud and rough

Flat, BS (N), Liver span 7 cm, traubes space dull, soft,

Extremities

tenderness (+) at epigastric area

Warm, moist, edema (-)

LABORATORY FINDINGS
LAB

Leukocyte

RESULT

NORMAL VALUE

LAB

RESULT

NORMAL
VALUE
136-145
mmol/l

7,850

3,500-

Sodium

131

Hemoglob

10.9

10,000/L
11.0-16.5

Potassium

4.01

ine
MCV
MCH
PCV
Thromboc

3.5-5.0
mmol/L

87.60
30.60
31.20
60,000

Chloride

109

RBS
Ureum

67

98-106
mmol/L
>200 mg/dL
10-50 mg/dL

Creatinine
Albumin
Anti
dengue
IgM
IgG

1.49

yte
SGOT
SGPT
Bil T
Bil D
BIl I

123
229

URINALYSIS
1.005
SG
5.5
PH
Leucocyte
Nitrite
Protein
Glucose
Erythrocyte
Keton urine
Urobilinogen
Bilirubin
-

g/dl
80-93 m3
27-31 m3
35-50%
150,000390,000/l
11-41U/L
10-41U/L
< 1.00
mg/dL
< 0.25
mg/dL
< 0.75
mg/dL
10 x
Epithelia
Cylinder
Hyaline
Granular
Leukocyte
Erythrocyte

0.7-1.5 mg/dL
3.5-5.5 g/dL

Negativ
e
Negativ
e

40 x

0.5
-

Erythrocyte
Leukocyte
Crystal
Bacteria

4.1
0.6
2.7

CXR :
AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue
normal, Phrenicocostalis angle D/S sharp, Hemidiaphragm D/S dome shape, BVP increase, thickening
of right hillus, infiltrate at middle area, CTR 50%
Conclusion : pneumonia

ECG:
Sinus rhthym:93 bpm

PR interval
: 0,14
QRS complex
: 0,10
QT interval
: 0,32
Frontal Axis
:N
Horisontal Axis
:N
Conclusion : normal ECG
CUE&CLUE
Male/45 YO
-6 days fever,
high grade,
continuous,
-headache,
muscle pain, joint
pain
-decreased of
appetite,nausea,
vomiting
-BP 140/70
-PR 92 x/m
-RR 22x/m
-Temp 39.80C
-CI (+), PCI (+)
ODS
-Tro 60,000
-OT.PT123/229
Male/45YO
-Intermittent
cough,
nonproductive
-high grade fever
- BP 140/70
-PR 92 x/m
-RR 22x/m
-Temp 39.80C
-Rh (+) at left
middle and basal
area of the lung
-CXR: infiltrate
at middle area of
the lung
Male/45 YO
-Decrease of
appetite
-Nausea
-6 days fever,
high grade,
continuous,
-headache,
muscle pain, joint

PL
1.AFI +
thrombocytopenia
+ increased of
transaminase

IDx
1.1
Leptospirosis
1.2 DHF
1.3 Acute Viral
Hepatitis

PDx
IgM anti HAV
HBsAg
IgM anti HCV

PTx
-O2 2-4 lpm prn
-Bedrest
-IVFD NaCl 0.9%
20 tpm
-Soft diet HCHP
2100 kcal/day
-Inj. Novalgin 3x1
amp (IV) prn
-Surface cooling

PMo
Subj
VS

2. Acute Lung
Infection

2.1 Pneumonia
CAP

Sputum
culture, gram
staining, and
sensitivity test

-O2 2-4 lpm n.c

S,VS
-Inj. ceftriaxone
2x1 gr (IV) skintest

3. Dyspepsia
syndrome

3.1 due to no.1

3.2 PUD
3.3. Gastritis
erosive

-Abdominal
USG
-Endoscopy

-Inj. Ranitidin
2x50mg (IV)
-Inj.
metochlopramid
3x10mg (IV)
-Omeperazole
2x20 mg (PO)

pain
- BP 140/70
-PR 92 x/m
-RR 22x/m
-Temp 39.80C
-Tenderness at
epigastric area