Follow up 08.

15
S: awarness begins to improve, there is no diarrhea, fever,
tachycardia, urine(+), seizure(-)
Physical Examination
General status :
Alertness : GCS 13 (E4V4M5) Temperature : 38.5°C
Dyspnea (+), cyanosis (-), edema (-), icteric (-), anemia (-)

Localized status:
Head : Anterior fontanel was not closed
Eye : Light reflexes (+/+), isochoric pupil, Ø 3mm/3mm, pale
inferior
palpebral conjunctiva (-/-), sunken eyes was found
Ear : Within normal limit
Nose : O2 nasal kanul 3 lpm
Mouth : Lip mucosa was dry
Thorax : Symetrical fusiform, epigastrial retraction
Heart rate : 188-192 beats/ minute, regular,
murmur (-) (N: 110-170 beats/ minute)
Respiratory rate : 40 times/ minute, regular, no
rales, stridor (+/+) (N: 24-46 times/ minute)

Abdomen : Soepel, normal peristaltic sound, no palpable

liver and spleen, poor skin turgor

Extremities : Pulse 200 beats/minute, regular, cold extremities,

capillary refill time
(CRT) <2 second, Sp. O2: 98%
TD : 90/50 mmHg (P50-90 : 90-105/53-65)

Anogenital : Anus (+)

Time Sens HR RR Sat. Tem
(bpm) (tpm O2 p
) (%)

08.15 GCS 13 198 44 99 38.5 -awarness begins

(E4V4 to improve, there is
M5) no diarrhea, fever,
tachycardia,
urine(-), seizure(-)
-IVFD RL
100cc/hour

08.45 GCS 14 182- 40 99 38.0 IVFD RL

(E4V5 188 100cc/hour
M5)
 Laboratorium result at Adam Malik Hospital
Hb : 10.8 g/dL pH : 7.41
Hematokrit : 33 % pCO2 : 17
Leukosit : 11.960/uL pO2 :190
HCO3 :10.8
Trombosit : 287.000/uL
Tot.Co2 :11.3
BE :-11.4
MCV : 75 fl Sat.O2 :100
MCH : 23 pg
MCHC : 33.1 g/dl Blood glucose :140

Neutrofil :55% Natrium :140

Limfosit :25.6% Calsium : 7.8
Kalium :3.5
Monosit :18.7%
Clorida : 106
Eosinofil :0.4
Basofil :0.3%
Time Sens HR RR Sat. Temp
(bpm) (tpm) O2
(%)

09.45 GCS14 170- 36-38 99 38.0 IVFD RL 100

(E4V5M5) 180 cc/hours

Correction of
hypocalsemia

10.30 GCS15 162- 34-35 99 37.8 IVFD RL 100

(E4V5M6) 168 cc/hour

Send to ward