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MORNING REPORT

Sunday, 22 January 2012

PHYSICIAN INCHARGE:IA : dr. Aditya , dr. Nanik, dr. Indra

IB : dr. Rusydah, dr. Andri

II : dr. Hidayat

III : dr. Nur samsu, SpPD-KGH

Summary of database

Male / 51 yo / W 27

Chief complaint : Acute diarrhea

Patient suffered acute diarrhea since 2 day before admission, suddenly onset,

frequency for about 4 times a day, volume for about 250 ml each diarrhea. 1 day

after, she complaint about high grade fever, joint and muscle pain, abruptly and it

made her blackout.

She diagnosed as hyperthyroid since young (12 yo), at that time she complaint about

palpitation, excessive sweating, decrease of body weight, and diarrhea. She

routinely controll at endocrinology outpatient clinic and treated with lugol soution 3x5

drop a day but she stopped controlled after married because there isnt complaint.

She has 3 children, her husband was die 3 years ago, her menstrual cycle was

normal.

Physical examination

BP = 80/60 mmHg PR = 118 bpm RR = 22 tpm Tax : 38.6 C

General appearance looked moderatlly ill; GCS : 456

Head Anemic ( + ) Icteric ( - )

Neck JVP R + 0 cm H2O

Thorax cor Ictus invisible, palpable at AAL(S) ICS VS1 – S2 single, additional sound ( - )

lung Simetric, SF D = S, V V Rh - - Wh - -

V V - - - -V V + + - -

 Abdomen Flat, soufel, bowel sound (+) normal, liver span 8 cm, traube space tympani

Extremities No abnormality

Laboratory finding

Lab Value Lab Value

Leucocyte 10,300 3500-10000/µL Na 128 136-145 Mmol / L

Hemoglobin 8.2 11,0-16,5g/dl K 3.05 3,5-5,0 Mmol / L

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PCV 25.6 35-50% Cl 108 98-106 Mmol / L

MCV 80-91 Ca

MCH 26,5-33,5 P

Trombocyte 69.000 150000-390000 Alb 3.5 – 5.5 g/dl

RBS 89 (<200)mg/dL PPT 18.0 C 11.8

Ureum 30.2 10-50mg/dL APTT 37.7 C 28.4

Creatinine 1.11 0,7-1,5mg/dL SGOT 57 11-41U/L

Granulocyte 9,400 SGPT 27 10-41U/L

INR 1.56

CXR

 AP position, asymeric, KV too strong, Less inspiration, trachea in the midlle, soft tissue and

bone Normal, Phrenico costalis angle on Right and Left sharp, Hemidiaphragm dome shapeLung D/S clear.

Lung : Clear 

Cor : site normal, size CTR 55 % and shape normal

Conclusion : normal CXR

ECG

Sinus Rhythm, HR 130 x/m

Frontal Axis : Normal

Horisontal Axis : Counterclock wise

PR interval : 0.12”

QRS complex : 0.06”

QT interval : 0.36”

Conclusion : Sinus tachycardia, HR 130 bpm

CUE and CLUE P. List I. Dx P. Dx P. Th/ P. Mo/

female/ 43 YO Ax:

 Abdominal pain, diarrhea since 2days ago, fever since 1 day ago,excessive sweating, diagnosed

as thyroid disease since 12 yearsold and treated with lugol solution3x 5 drop and stopped sice 20years agoPE:

PR 118RR 22Mass at her neck, diffuse,tenderness (-), bruit (-)Rhonkhi at basal area of bilaterallungsLab :

Burch+Wartofsky score 45

Wayne index 18

1. thyroidstrorm

1.1 Grave

Disease

1.2 De

Quervain

thyroiddisease

13 Hashimotothyroiditis

TSH, Free T3,T4

Bed rest1900 kcal diet per dayO2 - 4 lpm n.cLugol solution 3x5 drop(po)

Inj. Dexamethason 1x2mg (iv)PO: PTU 3 x 200 mg 

Pulse rateECGSubjective

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Female/43 yo Ax:

Diarrhea since 2 days ago,frequency 4 times aday, volume250 cc, nausea nd vomiting,fever, decrease of apettite

PE:

BP 80/60 mmHgPR 118 tpm,Shunken eyesLab :

Daldijono score 4

2. acute waterydiarrheamoderatedehidration

2.1 dt no12.2 viralinfection1.3

Plasmaspeciic gravity

Intravenous volumerepletionRL4x4.5x1 litre

151200 ml/2 hours iv drip

continous withmaintenance 20 dpm (iv) Atapulgite 2 tab/ diarrhea

BloodpressureSubjectivecomplaint

Female/43 yo Ax 

Dry Cough for 4 daysPE 

 Aus : v v

v vbv bv

Rh: - -- -+ +

LAB

Leucocyte: 10.300Granulocyte 9300PORT score : 73

3. Acute LungInfection

3.1Pneumonia/C AP

Sputum cultur and sensitivitytest

Ceftriaxone 2x1 g (iv)skin test

Subjectivecomplaint

Female/43 yo Ax :

Pale conjunctiva (+)LabHb 8.1MCV 84MCH 27

4. Anemianormochrom

normocytair 

3.1related tono 1

3.2 chronichinflamation3.3 Hemolyticanemia

TIBCSerum iron

Bil T/D/I

Treat underlying disease Recheck HbVital sign

Female/43 yo Ax 

High grade fever since 1 daysagoPE 

T ax 38.6Pale conjunctiva

LABHb 8.1Trombocyte 69,000

5. Bisitopenia 5.1 Denguefever 5.2 other arboviral inf.5.3 MDS5.4 Aplastic Anemia

BMP Confirm diagnosed Serial CBC

THANK YOU