Herwindo Pudjo B. Morning Report Saturday October, 27nd. 2011 Physician in charge Jaga 1A Jaga 1B Jaga 2 Jaga 3 : dr.

Suyoso, dr. Herwindo, dr. Joko : dr. Rivai, dr. Nani : dr. Mia : dr. Nursamsu, SpPD-KGH

Mr. Dian Agus /23 yo/w.24b Chief complaint : Fever Patient presented with fever as a chief complained. This fever felt since 4 days before admission. This fever felt gradually and then at nite become high fever followed by shivering and sweating, after that the fever is relieve by itself. It happened everyday, and felt at morning, noon, and afternoon. Beside fever he also felt pain at his extremity joint since 2 days before admission, felt all day. And he also said that his appetite is decreasing since 4 days before admission, in this last 2 day he felt nausea without vomiting. He had history of went to Kalimantan 2 weeks ago, he stayed there for 1 week, and said that during his stay he went to go hunting at Kalimantan with his brother.

hysical examination: General appearance : looked moderately ill GCS : 456 BP : 125/70 mmHg, PR : 82 bpm, regular, strong RR : 20 tpm, regular, tachypneu Tax : 36.7oC : pale conjungtiva (-), sclera icteric (-), JVP R+2 cm H2O (30o) : cor ictus invisible palpable at ICS V MCL Sinistra S1/S2 single, murmur (-) , LHM as ictus, RHM as SL Dextra Pulmo Symmetric Au v v Rh - - Wh - - Pr s s v v -- s s v v -- s s : flat, bowel sound normal, supple, liver span 9 cm, traubes space tympani, shifting dullness (-). : Anemic (-) ict (-) Warm

Head and Neck Thorax

Abdomen Extremities

Laboratory Finding Laboratory Hb Leucocyte Thrombocyte Hematocrite MCV MCH RBG Ureum Creatinine 13.1 10,400 190,000 40,0 86 28.2 154 41.9 0.91 Finding Normal Range 11.0 16.5 3500 10000 150000 390000 35.0 50.0 80 97 26.5 33.5 < 200 mg/dL 10 50 m/dL 0.7 1.5

Herwindo Pudjo B. SGOT SGPT SE Natrium Kalium Chlorida 19 26 142 4.56 100 11 41 10 41 136 145 3.5 5.5 98 106

Urinalysis (waiting for result) SG 1020 pH 5.0 Leu + Nitrite Prot 3+ CXR : not yet performed Glu Keton Urobil Bil Ery 10x epitel 40x erytrocyte Leukocyte Bactery

ECG

sinus rhythm HR 84 bpm, frontal axis normal, horizontal axis normal, int PR 0.12 , QRS complex 0.08, QT int 0.24, Conclusion : Normal ECG

s Cue and Clue

Male, 23 yo History of Acute Fever with shivering and sweating Dyspepsia Arthralgia BP : 120/70 PR : 84 RR : 20 Tax : 36.9

Problem List
1. AFI + Dyspepsia Syndrome

Initial Diagnose
1.1 Malaria 1.2 Dengue fever 1.3 Chikunguya

Planning Diagnose
Thin and thick smear, Malaria ICT

Planning Therapy
IVFD NS 30 tpm Soft diet HPHC In. metoclopramide 3 x 10 mg PO : omeprazole 2 x 20 Paracetamol tab 3 x 500

Planning Monitoring
CBC serial Subjective