PENINJAUAN KEMBALI RISIKO JANGKA PANJANG BUNUH DIRI SETELAH
EPISODE PERTAMA PSIKOSIS Dutta et al Arch Gen Psychiatry.
2010;67(12):1230-1237
MORNING REPORT
Wednesday, April 15th 2015PATIENT IDENTITYName:
IKBAMR:15020478Age: 40 y.oSex: MaleReligion: HinduStatus:
MarriedOccupation: EmployeeAddress: Jl Tk Yeh Ayung no.38
DenpasarDate of Arrival: 14/04/2015
ANAMNESISChief Complaint : DiarrheaPatient complained diarrhea
since 2 days BATH. The diarrhea was more than 10 times /day, with
volume glass every defecation. The stool was watery, yellowish in
colour with mucus and blood. Patient said theres red blood came out
with his faeces since 3 months ago. Patient also complained
abdominal pain since 2 days BATH. Pain was felt like twisting in
lower abdominal region. Pain was felt before he wanted to
defecate.Patient also complained fever since 1 day BATH &
occured suddenly. Fever was felt all over the body, but fever was
decreasing slowly.Before diarrhea, patient consumed fish that was
bought in traditional market.Urination was decreased. Last
urination was 10 hours BATH about less than glass.Patient said he
felt thirsty all the time and his appetite was decreased. History
of vomitting was denied.History of PatientMedication HistoryPatient
went to General Practitioner 2 days BATH and got medication
Novaflox 500mg, Primodiar, Zegase, and Oralit. Patient said after
taking those drugs, the symptoms not getting better and patient
still have diarrhea 8-10 times a day.History of PatientPast
HistoryHistory of this complain before was denied. No history of
heart ds, liver ds, renal ds, hypertension or DM before.
Family HistoryNo family members had same complains as the
patient. No history of heart ds, liver ds, renal ds, hypertension
or DM in family members
Personal & Social HistoryPatient is an employee. Patient
didnt smoke and drink alcohol.PHYSICAL EXAMINATIONGeneral
appearance: Moderately illLevel of consciousness: CM (E4V5M6)
Vital Sign: BP: 90/60 mmHgRR: 18 x/minPR: 68 x/minTax:
36,3CHeight: 172 cmWeight: 63 kgBMI: 22,71 kg/m28Eyes: conj. pale
(-/-); icterus (-/-); Rp +/+ isocoric, shrunken eyes (+/+)
ENT: Tonsils T1/T1; pharyngeal hyperemia (-); tongue normal; lip
cyanosis (-) lip wet (+) Neck : JVP PR + 2 cmH2O; lymph node
enlargement (-)
9Thorax: Simetris, retraction (-)
CorInspection : Ictus cordis unseen Palpation : Ictus cordis
unpalpablePercussion :UB : ICS II SLB : at MCL S ICS VRB : at PSL
DAuscultation : S1 S2 single regular, murmur (-)
PoInspection : Symetric (static and dinamic)Palpation : VF N/
NPercussion : sonor/sonorAuscultation : Vesikular + / + , Rh -/-,
wh -/-
10Abdomen : Inspection: Distention (-); ascites (-)Auscultation:
Bowel sounds (+) Percussion: TympaniPalpation: Tenderness on
palpation (+); liver & spleen not palpable quick return of
turgor (< 2)
Extremities: Warm +/+; edema -/- +/+ -/-Woman washer hands
(-/-), CRT 30 x/minSkin turgor Facies cholerica (Sunken eyes,
sunken cheeks)1Vox cholerica (hoarse)Cold extremitiesWasher women
handCyanosisAge 50 60Age > 603/15 x 10% x 63kg x1L= 3, 78 L
