MORNING CASE REPORT

June 15th, 2012

 PATIENT IDENTITY
• Initial : SIW
• Sex : Male
• Age : 60 years old
• Religion : Hindu
• Ethnic : Balinesse
• Marital Status : Married
• Address : Br. Baturinggit Kaja, Kubu,
Karangasem
• Occupation : Farmer
• ToA : 05.00 pm
 ANAMNESIS
Chief Complaint : Fever
Present History :
 Patient came to the hospital with complaint of sudden
and continous fever since 15 days BATH. He said that
the fever was felt like burning sensation over the body
and wasn’t relieved with paracetamol.
The fever sometimes accompanied by shivering.
 Patient also complained about yellowing of the skin
and the eyes since 10 days BATH. He also complaint in
changing the color of urine. He said the color of urine
was brownish yellow like tea. No pain on urination.
 Anamnesis Cont.....
 Px also complaint pain on his calf muscle on legs since
10 days BATH. This complaint didn’t get better with rest.
 He also complaint cough since 7 days ago, without
sputum and blood.
 Urination and defecation was said to be normal
 The was no breathlessness, no nausea and
vommiting, no epigastrial pain.
Loss of body weight and history of haemorrhage was
denied.
 Past History
 No history of having the same complaint before.
History of asthma, hypertension, DM, and heart disease
was denied by the patient.
 No history of liver and renal diseases.
 Family History
• None of her family have history of liver disease
and renal ds.
• Diabetes mellitus (-), heart Ds (-), HT (-).

Social History
• The patient has a habbit of drinking alcohol
since 5 years.
• Px is a farmer. He work in farmland everyday.
 Physical Examination
Present status:
• General condition : moderately ill
• Level of Consciousness : E4V5M6/CM
• BP : 110/70 mmHg
• Pulse rate : 115 bpm
• Resp. rate : 20 bpm
• Axillary temp. : 38o C
• Weight : 65 kg
• Height : 170 cm
• BMI : 22,5 kg/m2
• VAS : 4/10 on both calf muscles
PHYSICAL EXAMINATION
• General Status
– Eye : anemic -/-, ict +/+, pupillary reflexes +/+ isokor, conjunctival
suffosion -/-
– ENT : Tonsil Normal, Pharing: hiperemis (+), gland swelling (-)
– Neck : JVP PR +0 cm H2O, nuchal rigidity (-)

– Thorax : symmetrical, no retraction

Cor : I : ictus cordis unseen
Pal : ictus cordis palpable in MCL ICS 5
Per : UB : ICS 2
RB : right PSL
LB : ICS 5 MCL sinistra
Aus: S1S2 Single Regular, Murmur (-)

Lung: I : Symetrical
Pa : VF N/N
Per : sonor on both lung
Aus : ves +/+, wh-/-, rh-/-
 PHYSICAL EXAMINATION
 Abdomen : I : Dist (-)
Aus : Bowel sound (+) normal
Pal : Liver/spleen unpalpable,
tenderness (-)
Per : Tympany(+)

 Extremeties : Warm + + Edema - -

+ + - -
Pain : gastrocnemius pain +/+
 LABORATORIES
• Complete Blood Count

Parameter Nilai Unit Remarks Nilai Normal

WBC 22,9 103/μL High 4,1-11,0
#Ne 16,9 103/μL High 2-7.5
#Lym 2,62 103/μL Normal 1,0-4,0
#Mo 3,06 103/μL High 0,1 – 1,2
#Eo 0,062 103/μL Normal 0 ,0 – 0,5
#Ba 0,277 103/μL Normal 0,0 – 0,1
RBC 3,45 103/μL Low 4,5 – 5,9
HGB 9,67 g/dl Low 13,5 – 17,5
HCT 27,1 % Low 41,0 – 53,0
MCV 78,5 fl Low 80,0 – 97,00
MCH 28,0 pg Normal 27,0 – 31,2
MCHC 35,7 g/dl Normal 31,8 – 35,4
PLT 300,00 103/μL Normal 150,00-440,00
 LABORATORIES
• Blood Chemistry

Parameter Result Unit Remarks Reference range

SGOT 53,12 U/L High 11,00 – 33,00
SGPT 26,94 U/L 11,00 – 50,00
BUN 15,77 mg/dL 10,00 – 23,00
Creatinine 0,68 mg/dL 0,50 – 1,20
GDS 129 Mg/dL 70,00-140,00

Total Bilirubin 1.5 High 0,3-1,3

Bilirubin direk 1,4 High <0,8

Bilirubin Indirek 0,1 0-0,3

Albumin 2,96 Low 3,2-4,5

Kalium 3,82 3,2-5,3

Natrium 137,10 136-145

 LABORATORIES
• Urinalysis
Parameter Result Unit Remarks Reference range
pH 5,00 - 5–8
Leucocyte 25,00 Leu/uL 1+ Negative
Nitrite Pos - Negative
Protein 75,00 mg/dL 2+ Negative
Glucose norm mg/dL Normal
Ketone 5,00 mg/dL 1+ Negative
Urobilinogen norm mg/dL 4+ 1 mg/dl
Bilirubin 6,00 mg/dL 3+ Negative
Erytrocyte 25,00 ery/uL 2+ Negative
Spesific Gravity 1,02 - 1,005 – 1,020
Colour brown - p. yellow - yellow
SEDIMEN URINE
Leucocyte 3-5 /lp <6/lp
Erytrocyte 1-2 /lp <3/lp
Silinder - /lp ---
Others Bactery (+) /lp ---
ECG ECG INTERPRETATION

Sinus ryhtm
Heart rate 115x/mnt
Axis normal
P wave normal
QRS complex normal
ST change (-)

Conclusion : Sinus
Tachycardi
THORAX PA
- CTR : 50 %, waist (+)
- Costophrenic angle sharp at
both side
- Bronchovascular normal
- Consolidation (-)
- Conclusion : Normal CXR
 ASSESSMENT

- OBSERVASI FEBRIS + JAUNDICE e.c.

SUSPECT LEPTOSPIROSIS
dd/ CHOLECYSTITIS
 THERAPY
• Hospitalized
• IVFD Nacl 0,9 % 20 dpm
• Diet high calories and high protein
• Paracetamol 3 x 750 mg
• DMP 3 x 20 mg
• Antibiotic : Ceftriaxone 1 gr/day IV
 PLANNING DIAGNOSIS
- Ig M anti Leptospira
- Viral Hepatitis Serology (anti HAV, anti
HBsAg)
 MONITORING

• Vital sign
• Complaints
Thank you....