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    Physician in Charge: Ulfia Azmi Mustika Hany R Henny Dwi M. Rizaldi

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    Bethari Abi Safitri
    This document summarizes the medical record of a 52-year-old male patient admitted to the hospital on September 24th, 2017 with the chief complaints of loose stool and vomiting. The patient has a history of diabetes mellitus and was found to have decreased skin turgor, sunken eyes, abdominal pain, and laboratory abnormalities including high blood glucose, elevated creatinine and low sodium. The physician's diagnoses include acute watery diarrhea, diabetic complications, acute kidney injury, hyponatremia, and an allergic reaction. The treatment plan involves IV fluid resuscitation, electrolyte replacement, diabetic and rehydration management.

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    Physician in Charge: Ulfia Azmi Mustika Hany R Henny Dwi M. Rizaldi

    Uploaded by

    Bethari Abi Safitri
    63 views14 pages
    This document summarizes the medical record of a 52-year-old male patient admitted to the hospital on September 24th, 2017 with the chief complaints of loose stool and vomiting. The patient has a history of diabetes mellitus and was found to have decreased skin turgor, sunken eyes, abdominal pain, and laboratory abnormalities including high blood glucose, elevated creatinine and low sodium. The physician's diagnoses include acute watery diarrhea, diabetic complications, acute kidney injury, hyponatremia, and an allergic reaction. The treatment plan involves IV fluid resuscitation, electrolyte replacement, diabetic and rehydration management.

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    This document summarizes the medical record of a 52-year-old male patient admitted to the hospital on September 24th, 2017 with the chief complaints of loose stool and vomiting. The patient has a history of diabetes mellitus and was found to have decreased skin turgor, sunken eyes, abdominal pain, and laboratory abnormalities including high blood glucose, elevated creatinine and low sodium. The physician's diagnoses include acute watery diarrhea, diabetic complications, acute kidney injury, hyponatremia, and an allergic reaction. The treatment plan involves IV fluid resuscitation, electrolyte replacement, diabetic and rehydration management.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    63 views14 pages

    Physician in Charge: Ulfia Azmi Mustika Hany R Henny Dwi M. Rizaldi

    Uploaded by

    Bethari Abi Safitri
    This document summarizes the medical record of a 52-year-old male patient admitted to the hospital on September 24th, 2017 with the chief complaints of loose stool and vomiting. The patient has a history of diabetes mellitus and was found to have decreased skin turgor, sunken eyes, abdominal pain, and laboratory abnormalities including high blood glucose, elevated creatinine and low sodium. The physician's diagnoses include acute watery diarrhea, diabetic complications, acute kidney injury, hyponatremia, and an allergic reaction. The treatment plan involves IV fluid resuscitation, electrolyte replacement, diabetic and rehydration management.

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    September, 25th 2017

    Physician in charge:

    Ulfia Azmi
    Mustika Hany R
    Henny Dwi
    M. Rizaldi
    Patient Identity

     Name : Mr. L
     Sex : Male
     Age : 52 y.o
     Religion : Islam
     Tribe : Banjar
     Nation : Indonesia
     Address : Bati-bati
     Occupation : private employees
    Date of Hospitalization : September, 24th 2017
    Autoanamnesis and
    heteroanamnesis
    Chief complained : loose stool
    Autoanamnesis:

    Patient complained has lost stool since 4 days ago, >4x/day,
    the stool is dominantly water, there is no blood and mucus in the
    stool. Patient also complained has vomited since 4 days ago,
    >5x/day, the composition of vomit are drool and food. Patient
    has had fever, 4 days ago, on and off, he has headache too. At ER
    patient’s condition was weak, his skin turgor decreased, and
    sunken eyes. Patient’s skin is itchy, swollen, pale red bumps all
    over his body and extremity after consuming cefixime. Patient
    has decreased of appetite since 5 days ago.
    Patient has history of diabetes mellitus since 4 years ago, and
    consumes metformin, glimepiride and insulin injection 1x/week.
    Patient also has diabetic foot.
    Autoanamnesis

     History of past illness: -



     History of family illness: -

     History of drug: (-)

     Allergic History : (-)

     Smoking History: (-)

     Social history : patient lives with his wife and 5 children.


    Physical Examination (September, 24th 2017 )
    TD: 110/70 mmHg HR: 96 x/mnt reguler, RR : 25x/mnt reguler Tax : 36.5 0C
    SpO2: 98%
    General appearance : General moderate ill GCS 4-5-6
    Skin
    Head

    Reduce skin turgor (+), papul eritem on body and extremity (+)
    Pale Conjungtiva (-), Sclera icteric (-), sunken eyes (+)
    Neck JVP R+2 cmH2O, lymph node (-)
    Thorax ( Pulmo ) I : Symmetric
    Pal : Symmetric, Fremitus Sound D=S
    Per : Sonor
    A:VV Rh - - Wh - -
    VV - - - -
    VV - - - -
    Cor I : Ictus Invisible
    Pal : Ictus Palpable at ICS V MCL Sinistra
    Per : LHM : ICS V MCL Sinistra
    RHM : ICS IV Linea Sternalis dextra
    A: S1 S2 single, Murmur (-)
    Abdomen Bowel sound (+) 15”/ M, Hepatomegali(-), Spleonomegali (-),
    Undulation (-), Shifting Dullness (-)
    Abdominal pain
    - + +
    - + + 
    - - -

    Extremities M 5 5 Cold extremity + +


    5 5 ++

    Wound - -
    ++
    CXR
     September, 24th 2017

     Position PA
     Enough QV
     Less inspiration
     No tracheal deviation
     Soft tissue and bone are normal
     Bronchovasculare pattern is
    normal
     No cavitas
     No fibrosis
     Hemidiphragma dome shape
     Costophrenicus angle is sharp
     Cardiophrenicus angle is blunt
     CTR side normal, size %, shape
    boot shape with scleroting orta
    ECG

     Sinus tachychardia
     Heart rate : 120x/min
     Frontal axis : normoaxis
     Horizontal axis : normoaxis
     PR interval : normal (0.12s)
     No RBBB or LBBB
     LVH (-)
    Laboratory Result 24-09-2017
    Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
    HEMATOLOGI


    Hemoglobin 12.5 12,50-15,60 g/dl Colorimetric
    Leukosit 13 4,65-10,3 thousand/ul Impedance
    Eritrosit 4.46 4,10-6,00 milion/ul Impedance
    Hematokrit 33.4 42,00-52,00 Vol% Analyzer Calculates
    Trombosit 216 150-356 Ribu/ul Impedance
    RDW-CV 14 12,1-14,0 % Analyzer Calculates
    MCV, MCH, MCHC
    MCV 75.1 75,0-96,0 Fl Analyzer Calculates
    MCH 28.0 28,0-32,0 Pg Analyzer Calculates
    MCHC 37.4 33,0-37,0 % Analyzer Calculates
    HITUNG JENIS
    Gran% 78.7 50,0-70,0 % Impedance
    Limfosit% 14.7 25,0-40,0 % Impedance
    MID% 6.6 4.0-11.0 % Impedance
    Gran# 10.2 2,50-7,0 ribu/ul Impedance
    Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
    GULA DARAH
    Gula Darah 327 <200 MG/DL GOD-PAP
    Sewaktu
    HATI
    SGOT 63  0-46 U/l IFCC
    SGPT 59 0-45 U/l IFCC
    GINJAL
    Ureum 118 10-50 Mg/dl Modiff berhelot
    Creatinin 4.3 0,6-1,2 Mg/dl Jaffe
    ELEKTROLIT
    Natrium 116.4 135-146 Mmol/l ISE
    Kalium 3.7 3.4 – 3.5 Mmol/l ISE
    Chlorida 99.9 95-100 Mmol/l ISE
    CUE AND CLUE PL IDx PDx PTx PMo Ped

    Ax: Acute Fecal - IVFD NS 0.9% Vital sign - Drink more


    • Loose stool, >4x/day, watery analysis 1,6lt for 2 hours CS water
    since 4 days ago diarrhea evaluate Electrolyte
    • Vomit >4x/days, [modera


    dehydration post
    dominated drool and te-heavy status then rehydration
    food dehydra - Attapulgit
    • Fever on and off tion] 2tab/diarrhea
    • Weakness
    • Always thirsty
    • Decrease urinate
    volume
    Physical examination:
    • Sunken eyes (+)
    • Reduce skin turgor (+)
    • Abdominal pain (+)
    • Bowel sound 15”/m

    Ax: DM T II - Levemir 10ui Vital sign -Diabetic diet


    • Patient diagnosed with - Atorvastin CS
    diabetes mellitus since complica 1x20mg GDP
    4 years ago and tion G2PP
    consumes metformin
    and glimepiride

    Lab:
    GDS: 327 mg/dl
    CUE AND CLUE PL Idx PDx PTx Pmo Ped
    Ax. -ulcus USG Dressing - Protect foot
    Patient has wound in his foot, diabetic doppler wound using
    history of diabetes mellitus since 4 ABI Score diabetic
    years ago Pus shoes
    Px. Ulcus diabetic on both foot culture - Foot hygiene


    Wagner 3

    Lab : - Azotemia - AKI IVFD NS 0.9% - Drink more


    Ureum 118mg/dl pre renal 20tpm water
    Creatinin 4.3mg/dl

    Ax. - Hyponatremia TTV


    • Loose stool, >4x/day, since 4 Hiponatrem correction CS
    days ago ia IVFD NaCl 3% Elektrolit
    • Vomit >4x/days, dominated 20tpm
    drool and food
    • Fever on and off
    • Weakness
    • Always thirsty
    • Decrease urinate volume
    wek
    Lab:
    Na+ 116.4mmol/l
    CUE AND CLUE PL Idx PDx PTx Pmo Ped
    Ax. - Allergic - Inj.
    - Hive skin after consuming reaction Difenhydramine
    cefixime. 1amp
    - Px. - Co.
    Papul eritema on his body and dermatovirology


    extremity

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