The patient is a 57-year-old female who presented with fever for one week and diarrhea for one day. She has a history of diabetes mellitus, hypertension, and coronary artery disease. On examination, she had a temperature of 36°C, tenderness in the right upper quadrant, and typhoid tongue. Laboratory tests showed hypercholesterolemia. She was assessed with acute gastroenteritis, likely typhoid fever given her recent travel history and presentation. She was started on treatment and monitoring for her multiple comorbidities.

1. DUTY REPORT
March 11th, 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

2. PATIENT RECAPITULATION
3rd Floor
-
4th Floor
1. Mr. H,34 yo. Low intake + anemia
2. Mr. D,35 yo. DHF
5th Floor
1. Mrs. S, 57 yo, febris d-8 susp thypoid fever
2. Mrs. T, 67 yo, Diabetic ketosis +CVD
6th Floor
1. Mr. G, 67 yo, low intake on geriarti
2. Mr. E, 45 yo, low intake+ ca nasofaring

3. PATIENT’S IDENTITY
•Name : S
•MR no : 282786
•Sex : female
•Age : 57 years old
•Religion : Moeslem
•Marital Status : Married
•Ethnic : Javanese
•Address : Jakarta

4. ANAMNESIS
Autoanamnesa on march 11th 2015 at 19.30AM
Chief Complaint
fever since 1 week before admmision
Additional Complain
loose stool

5. Present History

6. • 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)

7. • 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.

8. Past Illness
• Mild Stroke 8 years before admmision
• Hepatitis (-)
• Asthma (-)
• Allergy (-)

9. Family Illness
• Hipertension (-)
• Diabetes Mellitus (-)

10. HABITS AND LIFESTYLE
• History of travelling (+), she went to Batam
for 2 weeks last month.
•She has history eat unclean food

11. 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)

12. PHYSICAL EXAMINATIONGeneral Examination
• Head : Normocephal
–Eye : anemic conjunctiva (-/-), icteric
sclera (-/-), imature catarct OS, sunken
eyes (-), pseudofakia OD
–Ears : normotia, discharge (-)
–Nose : septum deviation (-), discharge (-)
–Mouth : typhoid tongue (-)
• Neck : lymph nodes enlargement (-),
JVP 5 – 2 cmH2o

13. COR
• Inspection: Ictus cordis (-)
• Palpation: ictus cordis not palpable , lift (-),
thrill (-),
• Percussion:
– Right border: ICS V, linea midclavicularis dekstra
– Left border: ICS V, linea midclavicularis sinistra
– Heart waist: ICS IV, linea parasternal sinistra
• Auscultation : regular 1st and 2nd heart
sound, murmur (-), gallop (-)

14. PULMO
Inspection : chest within normal shape, symmetries
on static and dynamic state
Palpation : tactile vocal fremitus both lungs were
symmetries.
Percussion : resonant both lungs
Auscultation : vesikular breath sound+/+, rales (-/-),
wheezing -/-

15. Abdomen : tenderness (+) at right upper
quadran, hepatomegaly(-), splenomegaly (-),
bowel sound (+) normal.
Extremities : pitting edema -/-, CRT < 2’

16. Laboratory resultsRESULT NORMAL RANGE
Hematologi rutin:
Hb 16,3 12 - 16 g/dl
Ht 50 40 – 52 %
Erythrocyte 6.3 4.3 - 6.0 mil /ul
Leukocyte 5760 4800 - 10800/ul
Thrombocyte 177800 150000 - 400000/ul
MCV 80 80 – 96 fL
MCH 26 27 - 32 pg
MCHC 32 32 – 36 g/dL
LABORATORIUM

17. RESULT NORMAL RANGE
Clinical chemistry:
Ureum 28 20 - 50 mg/dl
Kreatinin 1.0 0.5 – 1.5 mg/dl
Total Cholesterol 224 <200 mg/dL
Trigliserid 50 <160 mg/dL
HDL 49 >35 mg/dL
LDL 165 <100 mg/ dL
Fasting Blood
Sugar
165 70-100 mg/dl
2 PP BG 172 <140 mg/dL
Natrium 138 135 – 147 mmol/L
Kalium 4,3 3.5 – 5.0 mmol/L
Klorida 96 95 – 105 mmol/L

18. 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 quadran
Laboratory finding : hypercholesterolemia

19. PROBLEMS LIST
• Acute gastroenteritis
• DM type 2
• Hypertension grade 2
• Dyslipidemia
• History of CAD

20. Acute gastroenteritis
Anamnesis:
fever since 1 week before admmision, loose stool one day
before admission,
Physical examination
sunken eyes (-), dry mucos membrane(-)
Laboratory finding:-
Plan of diagnostic:
Widal test , feses analysis, feses culture,Tubex test, Blood
culture
Therapic plan : New diatab 3x 2 tab
less fiber food component
IVFD RL 20 tpm

21. DM type 2 (obesity, on therapy insulin)
uncontrolled
• Anamnesis:
history of DM on insulin, cataract (+), CVD (+)
Physical examination
Cataract (+) OS
Laboratory finding:FBG : 115 mg/DL, 2PP BG 170:12
mg/dL
Plan of diagnostic: Hb A1 C, urinalysis
Therapic plan :
diet : 1200 kkal/day
Novomix 20-0-20 U
consult to ophtalmologist

22. Hypertension grade 2
Anamnesis:
history HT (+) , no taking medication
Physical examination
BP: 160/80mmHg
Laboratory finding:-
Plan of diagnostic: ECG,
Therapic plan : Valsartan 1x 160 mg
Bisoprolol 1x 5mg

23. Dyslipidemia
Anamnesis:
-
Physical examination
-
Laboratory finding: total cholesterol ↑, LDL↑
Plan of diagnostic:-
Therapic plan : simvastatin 1x20 mg

24. History of CAD
• History of CAD
Anamnesis:
history of narrowing of heart blood vessel
Physical examination
-
Laboratory finding: -
Plan of diagnostic: ECG, echocardiogram,
coronary angiography
Therapic plan : aspilet 1x 80 mg

25. PROGNOSIS
Quo ad vitam : Dubia ad bonam
Quo ad sanationam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam

26. THANK YOU

27. 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

28. • 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 be done.