Difteri Geo

5/20/2018 Difteri Geo

1/14

MORNING REPORT

COASs IN CHARGE:

Geo Bertha Fernanda

Nur Alfi Dinari

MODERATOR : dr.Laksmi S., Sp.PD


2/14

SUMMARY OF DATA BASEFemale/19 yo/W.28

Chief complaint: Dysfagia

Patient suffered from dysfagia since 2 days ago, patient also suffered from

moderate grade fever since 3 days ago, abruptly onset, and subsided when he took

paracetamol but after 6 hours the fever was rising again.

Patien never suffered like this before. She got paracetamol tablet but her complaint

did not relieved. She went to PHC, and then from phc patient refered to Laboratory of

Microbiology FKUB for throat swab.


3/14

Patien had completed history of imunisation when she

was child. There wasnt history of contact with his neighbours

or her friends , who suffered from diphteria infection. But in

the area who the patient live, there was 2 patients have

diphteria.

History of past illness:

Same complaint (-)

Social occupation:


4/14

PHYSICAL EXAMINATION

BP : 110/70 mmHg PR : 96 bpm reguler,

strong

RR : 22 tpm Tax : 36,40C

General appearance : looked moderately ill

Looked normoweight

GCS 456 BW: 45 kgs

Head Pale conj. (-) sclera ict (-)

Neck JVP R+0 cm H2OThorax : Cor Ictus invisible and palpable at ICS V MCL S

LHM ~ ICS V MCL S, heart waist+

RHM: SL D

S1, S2 single with no murmur

Pulmo Symmetric, SF D=S

Abdomen bowel sound N, liver span 8 cm, traubes space tympani (+)

Extremities Edema (-) , warm acral


5/14


6/14

Culture result from throat swab

Positive Clostridium diphtheriae

(from Morfologic)


7/14

:

Result Normal Value

Leucocyte 5,95 /l 3.50010.000

Hemoglobine 12,90 gr/dl 11.016.5

MCV 81.90 Mm3 80-93 fL

MCH 27.50 Pg 27-31 fL

Eos/bas/neu/lim/mo 0/0,3/70,9/20

,7/8,1

PCV 38,40 % 3550

Trombocyte 162.000 /L 150.000390.000

RBS 77 mg/dl < 200

Ureum 17,40 mg/dL 10-50

Creatinine 0,55 mg/dL 0.71.5

SGOT 13 U/L 1141

SGPT 7 U/L 1041

Na 135 mmol / L 136145

K 3,56 mmol / L 3.55.0

Cl 107 mmol / L 98106


8/14


9/14

ECG (April 25th2013)

Sinus rhythm, Heart rate 85 bpm Frontal Axis : normal

Horizontal Axis : normal

PR interval : 0.12

QRS complex : 0.08

QT interval : 0.36

Conclusion: sinus rhythm with heart rate 97 bpm


10/14


11/14

CXR (April 24th2013)

AP position, symmetric, enough KV, less inspiration Soft tissue thin, Bone normal

Trachea in the middlle

Hemidiaphragm D/S dome shape

Phrenico costalis angle D/S sharp

Pulmo D/S :normal

Cor: site N, size CTR 50%

Conclusion : normal cxr


12/14


13/14

CUE AND CLUE PL IDx PDx PTx PMo

Female/22 yo

Ax:

-moderare fever for 3days ,

abruptly onset

- dysfagia

-Her neighbour has beensuffering from diptherie

PE:

Pseudomembran in tonsil

sinistra

BP:110/70 ,

HR: 96

RR:22

T ax :36,4

LabTrombosit :162.000

Throat swab culture:

Positive Clostridium

diphtheriae (from

Morfologic)

1. Acute

Tonsilitis

1.1 dt Diphterie

1.2 dt streptococal

1.3 dt infection

mononucleosis

-Throat swab

culture and

sensitivity

-Antibiotic

-CBC/24 hour

and ESR-Elec Test

-UL

-Soft Diet HCHP 2100 kcal/day

-NACL 0,9 % 20 dpm

Inj PPC 2x1,500.000

Inj ADS 20.000 IM

Po. parasetamol 3 x 500 mgSurface cooling

Vs

Subj

Urine

producti

onIntake


14/14

Condition this morning

GCS 456

Subjective: fever subsided

BP: 110/70 mmHg HR: 92 bpm

RR: 20 tpm

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