Morning Shift ReportSaturday, 16-11-2013dr.Dikara

Physician In Charge:1A: dr. Dikara, dr. Hesti dr. Fitranti (Cardio)1B : dr. Herman, dr. Nanik TII: dr. RifaiIII: dr. Sri Sunarti, Sp.PD

Summary of Data BaseFemale 60 yo/ w.28Chief complain : Diarrhea Patient suffered from diarrhea since one day before admission, frequency about more than 10x/day, watery > residual feces, volume about 1/2 glass of mineral water, without blood (-), foam (-) ,but with mucous (+) accompined some times with epigstric pain. She said about diarrhea, fist diarrhea like wash rice and mucous but since today diarrhea watery > residual feces , and persist with mucous. She did not eat something that different from daily food. She also complained felt thirsty since diarrhea She have hypertension since 7 month ago, BP about 140/-, but she didnt took drug because she didnt felt anything. History of hospitalization before was unknown History of social living: she is a house wife with 4 children

Physical ExaminationWard BP = 130/90 mmHgPR = 88 bpm, regular, strong RR = 18 bpmTax : 36,9C

General appearance looked moderate illGCS 456

HeadPale conjunctiva (-)Icteric sclera (-)

NeckJVP R + 0 cmH2O 30 degree

Chest Heart:Ictus invisible and palpable at ICS V MCL S LHM ictus RHM: SL DS1, S2 single, murmur (-)

Lung: Symmetric, SF D=S, normal percussion, Rh - - Wh - - - - - - - - - -

AbdomenSoefl, bowel sound (+) increase, liver span 8 cm, traubes space thympani, shifting dullness ( - ), epigastric tendenners (+)

ExtremitiesLeg edema -/- , warm acral

Laboratory Findings (November 16th 2013)LABVALUENORMALLABVALUENORMAL

Hemoglobin15.1011,0-16,5 g/dlRBS86< 200 mg/dl

MCVMCH81.8028.9080-96 fl26,5-33,5 pgUreum 21.6010-50 mg/dL

Leukocyte10.5203.500-10.000/LCreatinine 1.020,7-1,5 mg/dL

Eo/Bas/Neu/Limf/Mon1.0/0.2/80/12.6/6.00-4/0-1/51-67/25-33/2-5Natrium 136136-145 mmol/L

PCV42.7035-50%Kalium 3.963,5-5,0 mmol/L

Trombocyte 236.000150.000-390.000/LChlorida 11098-106 mmol/L

SGOT2911-41U/L

SGPT3010-41U/L

ECG ( November 16th 2013 ) Sinus rhytm with HR 90 bpm Frontal Axis: Norml Horizontal Axis:Normal PR interval : 0.16 QRS complex: 0,08 QT interval: 0,32Conclusion : Sinus rhytm HR 90 bpm

CXR ( November 16th 2013 )AP position, symmetric, enough KV, enough inspirationSoft tissue and bone: normalTrachea in the middleSinus phrenicocostalis dextra and sinistra dome sharpHemidiaphragma dextraand sinistra dome-shapeLung: BVP normal,Cor: site N, cardiac waist (+), size: CTR=45%Conclusion: Normal CXR

CUE AND CLUEPLIDxPDxPTxPMoPEd

Female/ 60 yo/W.28ADiarhea since yesterday >10x/dNauseaVomitingResidual feces (+)Mucous (+)

PETD: 130/90 N: 88 strongRR: 18Bowel sound (+)Epigastric tendenerrs (+)At 08:45 PM urinationLab:Leu: 10.520Neu: 80.0%Na: 136K: 3.96Cl: 110Ur: 21.60Cr: 1.02Daldiyono score: 11. Acute inflammatory diarhea with mild dehydration1.1 EIEC1.2 Shigelosis1.3 Salmnelosis

Fecal culture and sensitivity

Low fiber diet 1700kkal/dayIVFD NaCl 0.9% 20dpmInf. Ciprofloxacin 2x400 mg IVInj. Metoclopramid 3x10 mg (PRN) IV

PO:Ataplugit 2 atblet every diarrhea, maximal 10 tablet/day

S, VS,urine production Higine, low fiber diet.

Female/ 60 yo/W.28AHistory f HT since 7 month agoBP about 150/-PETD: 130/90 N: 88 strongRR: 18ECG: sinus rhytm 90 bpm 2. History of HT

Funduscopy

Low salt diet