MORNING REPORT

26th March 2017

IDENTITY

Name : SUP
Age : 63 years old
Sex : Female
Nationality : Indonesian
Religion : Islam
Occupation : Housewife
Address : Jl. Gunung Talang 1, Denpasar
Date : 26th March 2017 (21.26 WITA)
 Anamnesis

Chief Complaint : Diarrhea

Present Ilness
Patient came to emergency unit with diarrhea since 1
day BATH. She said only watery diarrhea withour blood
and slime. The frequency of diarrhea >5x/day and volume
about 100cc/diarrhea. Patient said that the diarrhea didnt
get better with drugs she bought from drugstores. Patient
said after she ates oranges yesterday, she got diarrhea
more than 5 times even at the midnight. Because of that
she felt malaise and couldnt do daily activities. Her family
then brought her to hospital.
Anamnesis

Patient also complained of nausea since 1 day BATH. The

re is no history of vomiting. She felt nauseas usually after
eat. Because of that the appetites decrease. She also had
fever since 1 day BATH. Suddenly she felt fever was high.
The fever decreased with paracetamol but it goes up
again after few hours.
Anamnesis

Past History
No history of having the same complaint before.

Patient have history of diabetes melitus since 1 year ago,

and regularly control to doctor. She take Glibenclamid for

the medication of diabetes melitus
History of hipertension, heart disease, and kidney disease
was denied.
 Anamnesis

Family History
There is no family with the same condition. No systemic

disease in his family

Social History
Patient was is a housewife. Patient has no history of

smoking or alcohol consumption.

PHYSICAL EXAMINATION

General appearance : moderately ill

Level of consciousness : Compos Mentis (E4 V5 M6)

Vital Signs
BP : 110/70 mmHg
PR : 88 x/min
RR : 20 x/min
Temp. Ax : 39 0C
PHYSICAL EXAMINATION

EYES
Anemic -/-

Icterus -/-

PR +/+ isochoric

ENT
Tonsils T1/T1

Pharing hyperemia (-)

Tounge (N), gum bleeding (-)

Lips cyanosis (-)

NECK
Gland enlargement (-), JVP + 0 cm H20
PHYSICAL EXAMINATION

THORAX
Cor :
Inspeksi : ictuss cordis unseen
Palpation : Ictuss cordis unpalpable
Percussion : UB : ICS II
LB : MCL ICS 5
RB : PSL D
Auscultation : S1S2 Single Regular, Murmur(-)
 PHYSICAL EXAMINATION

THORAX
Pulmo:
Inspeksi : Simetris statis & dinamis

Palpasi : Vokal fremitus N|N

N|N
N|N
Perkusi : sonor | sonor
sonor | sonor
sonor | sonor
Auskultasi : vesikuler +|+, ronkhi -|-, wheezing -|-
 PHYSICAL EXAMINATION

ABDOMEN
Inspection : distention (-)

Auscultation : bowel sounds (+) N

Palpation : tenderness on palpation (-), liver and spleen both

are not palpable
Percussion : tympanic (+)

EXTREMITIES
Warm +/+ edema - / -
+/+ -/ -
 LABORATORY EXAMINATION
Parameter Result Unit Reference range
3/L
WBC 17,96COMPLETE
(H) BLOOD10
COUNT (7/3/16) 4,10 11,00
-Neu 91,44% 16,43 (H) 103/L 2,50 7,50
-Lym 4,56% 0,82 (L) 103/L 1,00 4,00
-Mono 3,75% 0,67 103/L 0,10 1,20
-Eo 0,01 % 0,00 103/L 0,00 0,50
-Ba 0,24% 0,04 103/L 0,00 0,10
RBC 3,6 (L) 106/L 4,50 5,90
HGB 9,63 (L) g/dL 13,50 17,50
HCT 31,9 (L) % 41,00 53,00
MCV 88,59 fL 80,00 100,00
MCH 31,9 pg 26,0 34,0
MCHC 30,18 (L) g/dL 31,00 36,00
RDW 11,49 (L) % 11,60 14,80
PLT 304,2 103/L 150,00 440,00
 LABORATORY EXAMINATION
Parameter Result Unit Reference range

KIMIA KLINIK
AST/SGOT 12,7 U/l 11-27
ALT/SGPT 7,9 (L) U/l 11-34
BUN 26,0 (H) Mg/dl 8-23
Creatinin 1,38 (H) Mg/dl 0.70-1.20
Natrium 134 Mmol/L 136-145
Kalium 4,2 Mmol/L 3.50-5.10
BSA 356 <200
 IMAGING

Thorax Photo AP
Cor: Normal in size & shape
Pulmo: Bronchovascular pattern
normal, infiltrate (-), nodul (-)
Costophrenic angles: both sharp
Diaphragm: both normal
Bones & soft tissues: normal

Conclusion:
Heart and Lung within normal limit
 ASSESSMENT

o Gastroenteritis acute et causa suspect bacterial dd/viral

- Mild moderate dehydration
o Diabetic melitus type 2
PLANNING
THERAPY
IVFD NaCl 0,9% 20 lpm

Oralit ad libitum (io)

Cyprofloxacin 200 mg @12 hours (iv)

Domperidone 10 mg @ 8 hours (io)

Diet 1800 kkal

Apidra 6 unit @8 hours (sc)

Lantus 12 unit @24 hours (sc)

DIAGNOSTIC
HbA1c

FL, UL

MONITORING
Complaints

Vital signs, fluid balance

THANK YOU