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DUTY REPORT

th
16 December 2015

GP ON DUTY :
DR. IKE DAN DR. INDRI
COASS ON DUTY:
DANI & NITA

PATIENT RECAPITULATION

Outpatient
Inpatient

: 4 Patients
: 2 Patients

PATIENTS IDENTITY
Name

:
:

Mrs. D
Age
35 years old
Religion
: Moslem
Marital Status: Married
Occupation
: Honorer RSPAD
Address
: Jl. P. Mentawai Perum 3 BKS

ANAMNESIS
Autoanamnesis on 2nd December 2015
Chief Complaint : Fever 5 days prior to admission

CURRENT ILLNESS
The patient, female, 35 years old, was admitted in the
general ward with fever 5 days prior to admission. The
patient explains that the fever is intermittent. She also feels
that during the night, her temperature is higher when
compared to during the day. The patient cannot recall any
factor that improves or worsens her fever. The patient has
not consume any medication yet. In addition to the fever,
the patient complains of nausea and vomiting 5 days prior
to admission. The patient has vomited more than 5 times
ever since it started. The patient claims that she vomits up
to 1/2 glass of water each time. The contents of the vomit is
food and water.

CURRENT ILLNESS
The patient also complains of loose stools 5 days prior
to admission. The patient has defecated more than 5
times, each time measuring about 1/2 glasses of water.
The stool was more liquid than usual and contained
solid faecal matter as well as water. The patient
presence of blood in the stool. Black stools (-), Mucous
in stool (-). Patient also complains of abdominal pain.
The patient is unable to eat and drink properly because
of her nausea and vomiting which causes her to be
fatigued . The patient claims that there is nothing
abnormal with her urination process and her urine.

PAST ILLNESS
Hypertension (-)
Diabetes Mellitus (-)
Cornorary disease (-)
GI tract disease (-)

FAMILY ILLNESS
Hypertension (-)
Diabetes Mellitus (-)
Cornorary disease (-)
GI tract disease (-)

HABITS AND LIFESTYLE


The patient has a habbit of eating her meals

from street vendors.

PHYSICAL EXAMINATION
VITAL SIGNS
General State :
Consciousness

Moderate Sickness
: Compos Mentis
Blood Pressure
: 120/70 mmHg
Pulse
: 82 x/minute
Respiratory Rate :
18 x/minute
Temperature
: 38,8oC
Body Weight
: 55 kg
Body Height
: 162 cm
BMI
: 20,95 (Normoweight)

PHYSICAL EXAMINATION
General Examination
Head
: Normocephal
Eye
: anemic conjunctiva (-/-), icteric sclera (-/-)
Ears
: normotia, discharge (-)
Nose
: septum deviation (-), discharge (-)
Mouth : Dry mucosa (+), oral trush (-), leukoplakia (-), coated
tongue (+)
Neck
: lymph nodes enlargement (-)
Thorax : symmetric, intercostal retraction (-)
Cor
: regular 1st and 2nd heart sound, murmur (-), gallop (-)
Pulmo
: vesicular breathing sounds, ronki (-/-), wheezing (-/-)
Abdomen
: distended (-), bowel sound increased,
timpani, hepar & lien not palpable, umbilical regio
tenderness, Mcburney sign (-), Blumberg sign (-)
Extremities
: warm, pitting edema (-), clubbing (-), cyanosis (-)
CRT < 2 seconds

Laboratory Result

RESULT

NORMAL RANGE

Hb

14.7

13 - 18 g/dl

Ht

43

40 52 %

Erythrocyte

5.4

4.3 - 6.0 mil /ul

Leukocyte

24230

4800 - 10800/ul

Thrombocyte

235000

150000 - 400000/ul

MCV

81

80 96 fL

MCH

28

27 - 32 pg

MCHC

34

32 36 g/dL

Hematologi rutin:

RESULT

NORMAL RANGE

Ureum

27

20 - 50 mg/dl

Creatinin

0,6

0.5 1.5 mg/dl

Random Blood Glucose

93

< 140 mg/dl

Sodium

139

135 147 mmol/L

Potassium

4.4

3.5 5.0 mmol/L

Chloride

104

95 105 mmol/L

RESUME
The patient, female, 35 years old, was admitted at the general
ward with fever 5 days prior to admission. Fever was intermittent
and higher during the night. The patient has not consume any
medication yet. The patient also complaint of nausea and vomiting
4 days prior to admission. Patient has vomited more than 5 times.
Hematemesis (-). Patient also complained of loose stools 4 days
prior to admission. Patient defecated more than 5 times. Melena
(-), hematoschezia (-). Patient complained of abdominal pain as
well.
From the physical examination, temp= 38.8C, pulse =82/min,
Bp= 120/70 mmHg , RR=18/min. Dry mucosa on lips (+), coated
tounge (+), Tenderness on umbilical region.
Lab exam revealed leukocytosis (24230 /ul).

PROBLEMS LIST
Febris e.c. Susp. Thyphoid fever
Acute gastroenteritis with mild to moderate

dehydration

ASSESSMENT
Febris e.c. Susp. Thyphoid fever
Anamnesis:
.Intermittent fever 5 days prior to admission. Fever higher during the
night.
.Nausea and vomitting 4 days prior to admission
.Abdominal pain
1.

Physical examination:
Temperature = 38,8C
Tenderness on umbilical region
Lab examination:
Leukocytosis (24230)

THERAPY
Diagnostic Plan: Complete blood count+ diff count,

Urinanalyisis, electrolyte, Tubex TF


Therapeutic Plan
Ceftriaxone

1 3 grams drip in 250 ml of NS


Paracetamol 31 gram drip
Domperidon 3 10 mg

ASSESSMENT
2. Acute gastroenteritis with mild to moderate

dehydration.
Anamnesis:
.Loose stools 4 days prior to admission, more than 5 times
.Melena (-)
.Hematoschezia (-)
Physical examination:
Bp = 120/70 mmHg
Dry lips mucosa
Lab examination:
Leukocytosis (24230)

THERAPY
Diagnostic Plan: Complete blood count+ diff count,

Urinanalyisis, feces analyses, electrolyte.


Therapeutic Plan
IVFD

RL 2000 cc /24 jam


Diet soft food 1800kcal
Drinking water minimum of 2 litres
New diatab 2 tablets per Defecation, maximum 12 tablets.

PROGNOSIS
Qua ad vitam

: ad bonam
Qua ad functionam : ad bonam
Qua ad sanationam : ad bonam

DEHIDRATION STAGE

DALDIYONO SCORE

THANK YOU