DUTY REPORTMarch 11th, 2015

Approach Patient Acut Diarhhea With Comorbid Diseases

GP on duty: dr. Ananinta

Resident on duty: dr. Andi

Coass on duty: Bertha and Karina

Supervisor :

Dr Soroy Lardo SpPD FINASIM

Departmen Of Internal Medicine

Indonesia Army Central Hospital Gatot Soebroto

PATIENT RECAPITULATION

3rd Floor

-

4th Floor

1. Mr. H,34 yo. Low intake + anemia

2. Mr. D,35 yo. DHF

5th Floor

1. Mrs. S, 57 yo, febris d-8 susp thypoid fever

2. Mrs. T, 67 yo, Diabetic ketosis +CVD

6th Floor

1. Mr. G, 67 yo, low intake on geriarti

2. Mr. E, 45 yo, low intake+ ca nasofaring

PATIENT’S IDENTITY

•Name : S

•MR no : 282786

•Sex : female

•Age : 57 years old

•Religion : Moeslem

•Marital Status : Married

•Ethnic : Javanese

•Address : Jakarta

ANAMNESIS

Autoanamnesa on march 11th 2015 at 19.30AM

Chief Complaint

fever since 1 week before admmision

Additional Complain

loose stool

Present History

• Patient complain about having fever since 1 weekbefore admision. Fever was not fell suddenly high. Fever is felt not continously, fever is felt up and down, higher at night. The patient didn’t measure

the temperature.• Patient denied any chill, short of breathness,

cough. Urination is normal(no complaint).• Loose stool since 1 day before admission. The stool

was liquid, no mucus, no blood, the collor is yellowish green. The odor was feel like rotten egg. She has also complaint loose stool 10 times on the

day before admission and 4 times on thde day admmision. The volume about 250 (1/2 glass of

mineral water cup)

• She has taken new diatab on the day of admission and the loose stool stopped. She denied any

discomfort in her anus after defecation. She also complaint vomiting > 4x, contains water, clear

liquid, <1/2 glass of mineral water.

• She also DM type II since 2004. now on therapy with insulin 20-20-10. She has blurred vision and

has undergone cataract extraction 7 month before admmision. Tingling(-), lost of sensation (-),

decreased urination (-), wound (-), she routine go to the cardiologist because she has narrowing of

heart blood vessel. Take the medication but forget the name.

• HT (+), no medication.

Past Illness

• Mild Stroke 8 years before admmision

• Hepatitis (-)

• Asthma (-)

• Allergy (-)

Family Illness

• Hipertension (-)

• Diabetes Mellitus (-)

HABITS AND LIFESTYLE

• History of travelling (+), she went to Batamfor 2 weeks last month.

•She has history eat unclean food

PHYSICAL EXAMINATIONVITAL SIGNS• General State : Mild Illness

• Consciousness : Compos Mentis

• Blood Pressure : 160/80 mmHg

• Heart rate : 72x/minute

• Respiratory Rate : 18x/minute

• Temperature : 36oC

• Body Weight : 78 kg

• Body Height : 165 cm

• BMI : 28,65 (obesity gr 1)

PHYSICAL EXAMINATIONGeneral Examination•Head : Normocephal

–Eye : anemic conjunctiva (-/-), icteric sclera (-/-), imature catarct OS, sunken

eyes (-), pseudofakia OD

–Ears : normotia, discharge (-)

–Nose : septum deviation (-), discharge (-)

–Mouth : typhoid tongue (-)

•Neck : lymph nodes enlargement (-),

JVP 5 – 2 cmH2o

COR

• Inspection: Ictus cordis (-)

• Palpation: ictus cordis not palpable , lift (-), thrill (-),

• Percussion:

– Right border: ICS V, linea midclavicularis dekstra

– Left border: ICS V, linea midclavicularis sinistra

– Heart waist: ICS IV, linea parasternal sinistra

• Auscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-)

PULMO

Inspection : chest within normal shape, symmetries on static and dynamic state

Palpation : tactile vocal fremitus both lungs were symmetries.

Percussion : resonant both lungs

Auscultation : vesikular breath sound+/+, rales (-/-), wheezing -/-

Abdomen : tenderness (+) at right upper quadran, hepatomegaly(-), splenomegaly (-), bowel sound (+) normal.

Extremities : pitting edema -/-, CRT < 2’

Laboratory resultsRESULT NORMAL RANGE

Hematologi rutin:

Hb 16,3 12 - 16 g/dl

Ht 50 40 – 52 %

Erythrocyte 6.3 4.3 - 6.0 mil /ul

Leukocyte 5760 4800 - 10800/ul

Thrombocyte 177800 150000 - 400000/ul

MCV 80 80 – 96 fL

MCH 26 27 - 32 pg

MCHC 32 32 – 36 g/dL

LABORATORIUM

RESULT NORMAL RANGE

Clinical chemistry:

Ureum 28 20 - 50 mg/dl

Kreatinin 1.0 0.5 – 1.5 mg/dl

Total Cholesterol 224 <200 mg/dL

Trigliserid 50 <160 mg/dL

HDL 49 >35 mg/dL

LDL 165 <100 mg/ dL

Fasting Blood

Sugar

165 70-100 mg/dl

2 PP BG 172 <140 mg/dL

Natrium 138 135 – 147 mmol/L

Kalium 4,3 3.5 – 5.0 mmol/L

Klorida 96 95 – 105 mmol/L

Resume female, 57 yo. fever since 1 week before admision.

Fever was not fell suddenly high. Fever is felt not continously, fever is felt up and down, higher at night. Loose stool since 1 day before admission. The stool was liquid, no mucus, no blood, the collor is yellowish green. The odor was feel like rotten egg. She has also complaint loose stool 10 times on the day before admission and 4 times on the day admmision.

Physical examination : BP : 160/80, typhoid tongue (-),tenderness (+) at right upper quadran

Laboratory finding : hypercholesterolemia

PROBLEMS LIST

• Acute gastroenteritis

• DM type 2

• Hypertension grade 2

• Dyslipidemia

• History of CAD

Acute gastroenteritisAnamnesis:

fever since 1 week before admmision, loose stool one day before admission,

Physical examinationsunken eyes (-), dry mucos membrane(-)

Laboratory finding:-Plan of diagnostic:Widal test , feses analysis, feses culture,Tubex test, Blood

cultureTherapic plan : New diatab 3x 2 tab

less fiber food componentIVFD RL 20 tpm

DM type 2 (obesity, on therapy insulin) uncontrolled

• Anamnesis: history of DM on insulin, cataract (+), CVD (+)

Physical examinationCataract (+) OS

Laboratory finding:FBG : 115 mg/DL, 2PP BG 170:12 mg/dL

Plan of diagnostic: Hb A1 C, urinalysisTherapic plan :

diet : 1200 kkal/dayNovomix 20-0-20 Uconsult to ophtalmologist

Hypertension grade 2

Anamnesis:

history HT (+) , no taking medication

Physical examination

BP: 160/80mmHg

Laboratory finding:-

Plan of diagnostic: ECG,

Therapic plan : Valsartan 1x 160 mg

Bisoprolol 1x 5mg

Dyslipidemia

Anamnesis:

-

Physical examination

-

Laboratory finding: total cholesterol ↑, LDL↑

Plan of diagnostic:-

Therapic plan : simvastatin 1x20 mg

History of CAD

• History of CAD

Anamnesis:

history of narrowing of heart blood vessel

Physical examination

-

Laboratory finding: -

Plan of diagnostic: ECG, echocardiogram, coronary angiography

Therapic plan : aspilet 1x 80 mg

PROGNOSIS

Quo ad vitam : Dubia ad bonam

Quo ad sanationam : Dubia ad bonam

Quo ad functionam : Dubia ad bonam

THANK YOU

Comment

• Fever type Tropical infection

• Add another info about going to malaria-endemic area, change of diet

• Chief complaint shoud be “diarrhea” so it is consistent with the diagnosis/problem list of typhoid fever

• Should add another info about the blood pressure when the patient was diagnosed with hypertension and the blood glucose when she was diagnosed with DM type 2

• In Physical Examination if patient has fever, should check if she has relative bradycardia

• Patients that come with diarrhea, we should check the hemodynamic first, in case there is severe hypovolemiawhich is an emergency

• For the diagnosis of typhoid fever, check Widal titer (the diagnosis if the titer is >1/320) and should recheck the titer increase (> 4x increase within 1 week)

• The patient was given bisoprolol because she is suspected of having CAD

• To confirm the diagnosis of CAD, coronary angiography (cardiac cathetherization) should be done– If the patient’s condition is stable, treadmill stress test

can be done.