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Recapitulation
New patients : 2 patients
Stagnant patients : 4 patients
New Patients
Name
Age
Sex
Diagnosis
An. MI
11 yo
Dengue fever
By. Ny I
3 day
Stagnant Patients
Name
Age
Sex
Diagnosis
An. FI
1 yo
Observation of
seizure ec epilepsy
By BP
9 mo
Suspected meningitis
An. M
3 yo
Anemia gravis
An. AS
8 yo
Suspected
appendicitis
Identity
Name
Age
Sex
Adress
No MR
Admission
: An. MI
: 11 yo
: Male
: Jl. Rambutan
: 01407516
date : 20 January 2016, 20.00 WIB
Parents identity
Mother: Mrs.W, 35 yo, housewife
Father: Mr.Y, 38 yo, employee
Chief complaint
Fever since 3 days before admission
Recent history of
illness
3 days before
admission
Fever suddenly high,
happened all day, only
decrease with
antipiretic
There is headcahe,
retroorbital pain,
muscle and joint pain
There is no red spots
on skin, gum bleeding,
or nosebleed
Thereisisnausea
no cough,
There
and
cold,
painfull
vomitting especially
swallowing,
after eating.difficult
There isto
breath,
or pain
during
epigastric
pain
urination
2 days before
admission
1 days before
admission
No relieving of
symptoms
before
Never been hospitalized
Family history
Patients brother has just recovered from
Physical examination
General physics
: looks moderately sick
Conciousness
: Compos mentis
Vital sign
Blood pressure
: 110/65 mmHg
Heart rate
: 105 x/min, regular
Respiratory rate
: 24 x/min
Temperature
: 38,3 oC (axilla)
Nutritional status
BW
W/A
: 32 kg
BW/A = 88,8
%= 88 %
H/A = 97 %
BH
: 140 cm
W/H = 96 %
Nutrisional status : Normal
Physical examination
Head : normocephal
Eyes : conjungtiva anemic-/-, icterus of
Physical examination
Cor:
I
P
Physical examination
Pulmo
Result
Refrence Number
Hemoglobin
13,3
10,8-15,6 g/dl
Hematokrit
39
33-45 %
Leukocyte
3,4
5,0-14,5 thousand/ul
Trombocyte
103
181-521 thousand/uL
Eryhtocye
5,06
4,40-5,90 jt/ul
MCV
76,3
80,0-100,0 fl
MCH
26,4
26,0-34,0 pg
MCHC
34,6
32,0-36,0 g/dl
RDW
13,3
11,5-14,5 %
HEMATOLOGIC
MCV/MCH/MCHC
Diagnosis
Dengue fever
DD/DHF grade I
24 tpm macro
Parasetamol (10-15mg/kgbb/kali) : 4 x 500 mg po
Ranitidin 2 x 50 mg IV
Diet 1920 kkal/day
Bed rest
Monitor vital sign every 6-12 hours
Check DPL every 12 hours
Check dengue blot
RLD
PROGNOSIS
Ad Vitam
: Bonam
Ad Sanationam : Bonam
Ad Fungsionam : Bonam
Thank you