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Duty Report
Saturday, December 5th, 2015

Physician In Charge:
Jaga I : dr. Akta, dr. Alul, dr. Fachrureza, dr. Reni
Jaga HCU : dr. Gerry
Jaga CVCU : dr. Daya
Jaga IGD : dr. Maya, dr. Ramadhan
Chief Jaga : dr. Daru
Konsulen Jaga : dr. Gadis N, Sp.PD-FINASIM dr. Akta

Summary Of Database:
Mr Ahmad Khilmi /30 Y.O/W 27
Chief complaint: fever
Patient came with fever since 1 week ago, abruptly high and begin with the pain of his head. He took
medication with three kind of drug from private doctor. His fever was decrease but increase again at 4
days ago. His blood pressure was 90/60 and his thrombocyte was decrease the he got admission at
primary health care. His condition didn’t improver, the he was referred to RSSA.
He also had nausea, and decrease appetite since 5 days before admission.
He was passing urine and stool normally

Physical Examination

BP= 110/70 mmHg PR= 86  70 bpm RR =18 tpm Ax. Temp.= 39.5 37.5 C
General App. : looked moderate ill GCS : 456

Head 70Anemic conjunctiva (-) Icteric sclera (-) Lnn. Enlargement (-)
Neck
Thorax Cor Ictus invisible, palpable at 5ICS, MCL S
RHM ≈ S line D
LHM ≈ ictus
S1, S2 single, no murmur
Pulmo Symmetric; SF D=S; S| S V | V Rh -| - Wh -|-
S| S V | V -|- -| -
S| S V |V -|- -| -

Abdomen Flat, soft, BS shifting dullness (-), lank pain D/S -, suprapubis pain -,
Extremities Edema (-),

Laboratory Findings (October 23rd, 2015)

Lab Value (Normal) Lab Value
(Normal)
Leucocyte 1800 3.500-10.000/µL Ureum 9,60 10-50 mg/dL
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Haemoglobine 8,50 11,0-16,5 g/dl Creatinine 0,87 0,7-1,5 mg/dL

MCV 73,30 80-93 SGPT 305 0-33

MCH 25,50 27-31 SGOT 345 0-32
PCV 35-50% Natrium 131 136-145
Trombocyte 7.000 150.000- Kalium 3.61 3.5 – 5
390.000/µL

Eo/bas/neu/lim/m 0/0/46.6/47 Clorida 103 98 – 106

on .8/5.6

Anti dengue IgM Negatif

Anti dengue IgG Negatif

Lab Value Lab Value

Urinalysis 10 x

SG 1,010 Epithelia 0,1

PH 7,5 Cylinder -

Leucocyte - Hyaline -

Nitrite - Granular -

Protein - Leukocyte -

Glucose - Erythrocyte -

Erythrocyte 1+ 40 x

Erythrocyte 18,0

Keton urine - Eumorfik +

Urobilinogen - Dismorfik -

Leukocyte 2,0

Bilirubin - Bacteria 2,3x103

POMR
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CUE AND CLUE PL IDx PDx PTx PMo

Male 30 Yo 1. AFI day 7 1.1 Salmonellosis Igm Anti Inf NaCl 0.9% 1500 Vital sign
Ax: 1.2 Viral hepatitis Salmonell cc/hour CBC/24
Fever since 1 week 1.3 Malaria a Inj Ciprofloxacin hour
Nausea 1.4 Dengue Igm Anti 2x400 mg i.v
1.5 Other infection HAV, HbS
PE: Ag, Anti
Tax: 39.637.8 oC HB C
PR : 86  70 bpm
TD: 110/70

Lab
Wbc 1800/uL
Thrombocyte :
115.000 7000/uL
Shift to the right
0/0/46.6/47.8/5.6

2. 2.1 dt no 1 Blood Inj S

Lab: Pansitopen 2.2 hematological Smear Methylprednisolon 2 Ttv
Hb : 8.5 g/dL ia disorders SI, TI BC x62.5mg i.v Pmo
MCV 73.30 fl 2.3 drug induce Reticulocy CBC/24
MCHC 25.50 pg (chloramphenicol? te count hour
WBC 1800 /uL ?)
Trombocyte 7000
/uL

Male 30 Yo 3. Increase 3.1 viral hepatitis As above Hepatoprotector SGOT SGPT

Ax: Nausea transamina 3.2 transaminitis herb / 7days
SGOT/SGPT se + later
305/345 Nausea