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REPORT
Wednesday, April 15 2015
th
PATIENT IDENTITY
Name
: IKBA
MR
:15020478
Age
: 40 y.o
Sex
: Male
Religion : Hindu
Status
: Married
Occupation : Employee
Address : Jl Tk Yeh Ayung no.38
Denpasar
Date of Arrival: 14/04/2015
ANAMNESIS
History of Patient
Medication History
Patient went to General Practitioner 2 days BATH
and got medication Novaflox 500mg, Primodiar,
Zegase, and Oralit. Patient said after taking
those drugs, the symptoms not getting better
and patient still have diarrhea 8-10 times a day.
History of Patient
Past History
History of this complain before was denied. No
history of heart ds, liver ds, renal ds,
hypertension or DM before.
Family History
No family members had same complains as the
patient. No history of heart ds, liver ds, renal ds,
hypertension or DM in family members
PHYSICAL EXAMINATION
General appearance
: Moderately ill
Level of consciousness : CM (E4V5M6)
Vital Sign:
BP : 90/60 mmHg
RR : 18 x/min
PR : 68 x/min
Tax
: 36,3C
Height
: 172 cm
Weight : 63 kg
BMI
: 22,71 kg/m2
Thorax
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II S
LB
: at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : sonor/sonor
Auscultation : Vesikular + / + , Rh -/-, wh -/-
Abdomen :
Inspection
: Distention (-); ascites (-)
Auscultation : Bowel sounds (+)
Percussion
: Tympani
Palpation
: Tenderness on palpation (+);
liver
& spleen not palpable
quick return of turgor (< 2)
Extremities: Warm +/+; edema -/+/+
-/Woman washer hands (-/-), CRT <2
Status Lokalis
Rectal Toucher :
Terdapat massa uk. 2x2 cm bentuk reguler
Spinchter ani menjepit kuat
Mukosa recti licin
Ampulla recti dbn
Tidak terdapat pembesaran prostat
Pada handschoen terdapat darah berwarna merah
Result
Unit
Remarks
Reference range
WBC
23,67
103/L
4,5 11,00
47,00 80,00
-Ne
80,9%
19,15
103/L
-Ly
12,1%
2,86
103/L
13,0 40,0
-Mo
4,6%
1,09
103/L
2,00 10,00
-Eo
0,6%
0,15
103/L
0,00 5,00
-Ba
0,10%
0,03
103/L
0,0 0 2,00
RBC
4,31
106/L
4,00 5,20
HGB
13,7
g/dL
12,00 16,00
HCT
38,2
MCV
88,7
fL
80,00 100,00
MCH
31,9
pg
26,00 34,00
MCHC
35,9
g/dL
31,00 36,00
RDW
11,1
%
3
41,00 55,00
11,60 14,90
Result
Unit
SGOT
17
U/L
11,00 33,00
SGPT
16
U/L
11,00 50,00
Albumin
2,8
g/dL
BUN
19
mg/dL
mg/dL
98
mg/dL
Natrium (Na)
134
mmol/L
136-145
Kalium (K)
3,3
Mmol/L
3,50-5,10
Creatinine
Random blood
glucose
Remarks
Reference
range
3,40-4,80
10,00 23,00
0,50 1,20
70,00 140,00
ASSESSMENT
Acute Gastro Enteretis e.c Susp.
Bacteria DD/ Viral
Moderate Dehydration
Susp. Hemmoroid Interna Gr 1
Acute Kidney Injury Stage 1 e.c.
prerenal
Planning
Therapy
Hospitalized
Diet 1900 kkal
IVFD NaCl 0,9% 30 tpm
Paracetamol 3x500 mg prn
Doxycyclin 2x100 mg i.o
Asam tranexamat 3x500 mg i.o
PDx
Urinalysis
Monitoring
Vital sign
Complaints
BUN-SC @24 hours
THANK YOU
Dehydration Stage
Symptoms
Mild
Moderate
Severe
Mental status
Fully conscious
Irritable,
weakness
Apatis, lethargy,
unconsciousness
Thirsty feeling
Normal
Feeling
thirsty, really
want to drink
Cant drink
HR
Normal
Normal /
Tachycardi, in
severe case can
cause
bradycardi
Quality of HR
Normal
Normal /
decrease
Weak /
unpalpable
Eyes
Normal
Slightly
shrunk
Shrunk
Tears
Normal
Decrease
Wet
Dry
Severe Dry
Good
<2
>2
Normal
Longer
Longer
Moderate Dehydration
109% x 30 cc / kg BW / days
= 109% x 30 cc / 63 kg / days
= 2.060 cc / days
= 2060 cc / 24 hours = 85 cc in 1 hour
1 cc = 20 drops macro
85 cc x 20 = 1700 dpm in 1 hour
1700/ 60 minutes = 28 dpm = 30 dpm
DALDIYONO SCORE
Item
Thirsty/Vomit
Score
Apatis
Somnolen/Sopor/Koma
BP sistole 60-90
BP sistole 60
PR 120 x/min
RR > 30 x/min
Skin turgor
Facies cholerica (Sunken eyes, sunken
cheeks)
Vox cholerica (hoarse)
Cold extremities
Washer women hand
Cyanosis
= 3, 78 L