DUTY REPORT March 11 th , 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
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DUTY REPORTMarch 11th, 2015
Approach Patient Acut Diarhhea With Comorbid Diseases
GP on duty: dr. AnanintaResident on duty: dr. Andi
Coass on duty: Bertha and KarinaSupervisor :
Dr Soroy Lardo SpPD FINASIMDepartmen Of Internal Medicine
Indonesia Army Central Hospital Gatot Soebroto
PATIENT RECAPITULATION3rd Floor-4th Floor1. Mr. H,34 yo. Low intake + anemia2. Mr. D,35 yo. DHF 5th Floor3. Mrs. S, 57 yo, febris d-8 susp thypoid fever4. Mrs. T, 67 yo, Diabetic ketosis +CVD6th Floor5. Mr. G, 67 yo, low intake on geriarti6. 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 Complaintfever since 1 week before admmision
Additional Complainloose stool
Present History
• Patient complain about having 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. 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 Batam for 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
– Right border: ICS V, linea midclavicularis dekstra– Left border: ICS V, linea midclavicularis sinistra– Heart waist: ICS IV, linea parasternal sinistra
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 quadranLaboratory 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,
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/dLPlan 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 examinationBP: 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 CADAnamnesis:
history of narrowing of heart blood vesselPhysical examination
-
Laboratory finding: -Plan of diagnostic: ECG, echocardiogram,
coronary angiographyTherapic plan : aspilet 1x 80 mg
PROGNOSIS
Quo ad vitam : Dubia ad bonamQuo ad sanationam : Dubia ad bonamQuo 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 hypovolemia which 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