AFI Day 5 Yasmita Sip

7/28/2019 AFI Day 5 Yasmita Sip

1/11

DR. YASMITA-PPDS

IPD

MORNING REPORT

July 3rd,2012JAGA 1A : dr. Yasmita, dr. Camelia , dr.

Galuh(cardio)

JAGA 1B : dr. Asri , dr. Merici

JAGA 2 : dr. Satriyo

JAGA 3 : dr. Didi Candradikusuma, SpPDMODERATOR : dr. Atma Gunawan, SpPD-KGH


2/11

SUMMARY OF DATA BASE

Ms. Dwi /20 yo/W24A

Chief complain: fever

Px suffered from fever since 3 days before

admission, high grade fever, never reach normaltemperature although already consumed drugs

from GP before. She went to GP 1 day before

admission, got 3 kinds of

drugs(bimaflox,antalgin,other drug). But thecomplaint not relieved, then she went to RSSA

She complained about headache since 4 days

ago, esp.middle area of head, continously.


3/11

Complained about nausea and vomitting since2 days ago, vomit 2x, contain food, that made

her decrease of appetite, only ate 3-4

spoon/each Complained about nose bleeding at 1 day

before admission, about a quarter of glass

Px had sakit maag since the last 2 years,

often use promag to relieved the pain

Px is a college student in UB


4/11

PHYSICAL EXAMINATIONBP = 130/70 mmHg PR = 88 bpm,

reguler

RR =20 tpm Tax : 37.6C

General appearance looked moderately ill GCS 456 looks normoweight

Head Anemic - Icteric -

Neck JVP R + 0 cmH2O

30

Thorax: Cor: Invisible and palpable at ICS V MCL Sinistra

RHM SL Dextra

LHM ictus

S1 S2 single

Lung: Simetric, SF D = S, no additional breath sounds

Abdomen Soufle, BS (+) Liver span 8 cm, traubes space thympani

Extremities anemic -, acral warm, RL (+)


5/11

LABORATORY FINDING

Lab Value

(Normal)

Lab Value (Normal)

Leukocyte 3990 3.500-10.000/L

Natrium 136-145mmol/L

Haemoglobine 15.2 11,0-16,5g/dl

Kalium 3,5-5,0 mmol/L

PCV 45.1 35-50% Chlorida 98-106 mmol/L

Trombocyte 41000 150.000-390.000/L

RBS < 200 mg/dl

SGOT 524 11-41U/L UreumCreatinine

10-50 mg/dL0,7-1,5 mg/dL

SGPT 207 10-41U/L


6/11

CUE AND CLUE PL IDx PDx PTx PMo

Female/20yo

Febris day 3

HeadacheNausea and vomitting

PE:

BP. 130/70

PR.88

RR. 20

S. 37.6C

Warm acral

Rumple leed +Lab:

Hb 15.2

Leuco 3990

PCV 45.1

Trombo 41000

1. AFI day

3+thromb

ocytopenia

1.1 Dengue

hemorrhagic

fever grade II1.2 chikungunya

1.3 ricketsiosis

1.4 other arboviral

infection

IVFD RL 30 dpm

Soft diet 1900 kkal/day

Surface coolingInj. Metochlopramid 3x10mg

Subjecti

ve

BPHR

RR

CBC

bleedin

g


7/11

CUE AND CLUE PL Idx PDx PTx PMo

Female/20 yo

Nausea and vomitting

Epigastric pain

2. Dyspepsia

syndrome

2.1 due to no

1

2.2 gastritis

erosive

Inj. Metochlopramid 3x10mg

Po: omeprazole 2x20mg

Subj.c

omplai

ned

Female/20 yo

SGOT 524

SGPT 207

3. Increase

of

transaminase

3.1 reactive

3.2 viral

hepatitis

HbsAg

Anti

HCV

Confirm dx SGOT

SGPT


8/11

THANK YOU


9/11

Condition this morning

Fever (-)

BP. 120/80

PR. 90

RR. 20

Tax. 37

Warm acral


10/11


11/11

AFI Day 5 Yasmita Sip

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