Case report

Nama : Tiara Umur : 3 tahun 6 bulan Jenis Kelamin : Perempuan RM : 00.54.96.71 Alamat : Desa Gunung Lagan Kec. Gunung M Tanggal Masuk: 26 Februari 2013
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Keluhan Utama : Penurunan Kesadaran Telaah : Hal ini dialami os sejak 9 jam sebelum masuk rumah sakit. Pasien mengalami kecelakan. Pasien tertimpa buah kelapa yang jatuh dari pohonnya. Os juga sudah dibawa ke rumah sakit.
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o Pemeriksaan Umum
o Kesadaran o Tekanan darah o Nadi o Suhu o Pernafasan o Keadaan Umum o Keadaan Gizi : GCS 8 (E2M2V2) : 110/40 mmHg : 130 x/menit : 36,5 C : 40 x/menit : Buruk : Sedang
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 Primary Survey :
: Stridor, dilakukan pemasangan Orofaringeal Tube Breathing : Circulation : Disability : Airway

o Secondary Survey :
o

Physical examination
Generalized status

Body weight: 21 kg, Body length: 128 cm, Body weight in 50th percentile according to age: 30 kg Body length in 50th percentile according to age: 136 cm Body weight in 50th percentile according to body length: 26 kg BW/BL: / x 100% = 80,7% BW/age: / x 100% = 70 % BL/age : / x 100% = 94,11 %

Presence Status

: Sensorium: GCS 13 (E4V4M5), Temperature: 35C. Anemic (-), dyspnea (-), cyanotic (-), edema(-), icteric (-). Body weight (BW): 20 kg. Body length (BL): 128 cm. CDC: BW/Age = 70%, BL/Age = 94,11%, BW/BL = 80.7%

Localized status Head :Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-). Ear: within normal limit.
Nose: naso gastic tube (+), blood (+). Mouth: dry mouth(+). Neck : Lymph node enlargement (-), neck stiffness (-)

Chest :Symmetrical fusiform, epigastrial retraction(-),HR: 152 bpm, regular, murmur (-) RR : 38 x/minute, ronkhi (-/-).
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regular,

 Abdomen : Soepel (+), peristaltic (+), hepatomegaly (+) 4 cm BAC, spleen not palpable. Extremities : Pulse : unpalpable, blood pressure: unmeasured, clubbing finger (-), BCG scar (+) right arm, decrease of subcutaneous fat . Ano-Genitalia anus (+). : Male, within normal limit and

Parameters Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC)

Result

Normal Value 12 14.4 4.40 4.48 4.5 13.5

Unit

10.6 3.55 14.62

g% 106/mm3 103/mm3

Hematocrite
Trombocyte (PLT) MCV MCH MCHC RDW Neutrophil

27.50
19 77.50 29.90 38.50 13.00 44.90

37 41
150 450 81 95 25 29 29 31 11.6 14.8 37 80

%
103/mm3 fL pg g% % %

Limphocyte
Monocyte Eosinophil Basophil

23.60
30.20 0.00 1.300

20 40
28 16 01

%
% % %
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Neutrophil Absolute Limphocyte Absolute

6.57 3.45

2.4 7.3 1.7 5.1

103/L 103/L

Monocyte Absolute
Eosinophil Absolute Basophil Absolute Carbohydrate Metabolism Glucose

4.41
0.00 0.19

0.2 0.6
0.10 0.30 0 0.1

103/L
103/L 103/L

70.70

< 200

mg/dL

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Working Diagnosis: Dengue Shock Syndrome

Management: IVFD RL 20 ml/kgBW = > 400 cc bolus

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Follow Up
December 27th 2012 S O Head Blood in NGT (+), apatis (+) Sens: GCS 14 (E4V4M5), Temp: 36,5C, : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: blood in NGT (+), nasal canule (+) Mouth: dry mouth

Neck Chest

: Lymph node enlargement (-), neck stiffness (-) : symmetrical fusiform, HR: 116 bpm, regular, murmur (-) RR : 24 x/minute, regular, ronkhi (-)

Abdomen Extremities

: Soepel (+), peristaltic (+), liver can be palpable 4 cm under arcus costa : Pulse = 116 bpm, regular, adequate pressure/volume, blood pressure: 80/40, clubbing finger (-).

Ano- Genital

: Male,

A P

Dengue Hemorragic Syndrome Grade III Management: O2 1 liter/nasal canule IVFD 2 line 10cc/kgBW I: RL 5 cc/kgBW = 25 gtt/I (macrodrip) II: HES 5 cc/kgBW = 100 gtt/I (microdrip) PCT 3x 250 mg Inj. Ranitidine 20mg/8h/iv Fasting

R/

Consult to Infection and Tropic disease Division Check complete blood count/6hours Transfusion whole blood WB requirement: 6x20 x ( 11-6.9) = 492cc Transfusion ability: 5x 20: 100cc

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Working Diagnosis: Dengue Shock Syndrome Advice:

Consult results from Infection and Tropic Disease Division (December 27th 2012 )

Check CBC/6h Rontgen thorax PA Check Liver function test Fluid: 3 cc/kgBW/h (adjust to hemodynamic state) Monitoring blood pressure, HR, RR, temperature and urine output.
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