Name : Mr Tunjung , 24 YO Address : kp melati, pd gede CC : fever with shivering

Findings Fever with shivering Tiredness Nausea vomiting BP : 120/70mmhg PR : 88x/minute, adequate, regular RR : 22x/minute Temp : 38.50c Thoraks : Heart : Ins : simetric Pal : VF simetric right and left Per : Right:sonor Left : sonor Aus : left : basic breath sound vesikuler Right : basic breath sound vesikuler Abdoment : Ins : flat abdoment Pal : depress pain (-) defence muskular (-) Per : timpani , perccusion pain (-) Aus : intestine noise 5 times Edema (-) LAB FINDING: H2TL : Hb : 13,7 g/dl Leucosit : 10,5 Trombosit 200 Hematokrit 39,3 Assessment

TC CM

: friday/28 june 2013 /19:30

Therapy Diit : normal food, MM/ : Paracetamol 3x1 Planning Pro Home care enough rest

pharingytis DD : Dengue hemoragic fever

Subjective Data
Name: : MR Tunjung ,24 YO Address: : Kp Melati no 31 pd gede CC : shivering with fever CM: TC: Friday 28june 2013 /19:30

Anamnesis

Autoanamnesis dan Alloanamnesis on the date 21 june 2013, Time 01.30 WIB

Main Complaint

Fever with shivering since 4 days before admittance

Additional Complaints

Disphagia, nausea

Anamnesis
Patient came to the hospital with main complaints fever with shivering since 4 days before hospital admission. The pain come with another complaints such as nausea and dysphagia Hypertension (-) , nausea (+), vomit (-), DM (-), Urinating (+), defecating (+), intake (+)

Past Medical History and Treatment

Hypertension (-) History of Diabetes Melitus (-) Tuberculosis (-) History of trauma (-)

Family History (-) Social History Smoking (-) , Alcohol (-)

9/15/2013

Objective Data
Appearance :
moderate illness

awareness : E4V5M6; CM

TD : 120/80mmHg

HR : 88x /menit (adequate, reguler)

RR : 22x /menit

Temp : 38,5C

Objective Data
Head :Normocephali Konjunctiva anemic -/Sklera Ikterik -/-

JVP

: 5-2 cmH2O

pharynx : hyperemis (+) Tonsil : T2/T2

Thorax
Pulmonal Inspeksi Front back Left Right Static and dynamic symmetric Static and dynamic symmetric Static and dynamic symmetric Static and dynamic symmetric

Palpasi

Front

VF symmetric VF symmetric
Sonor Sonor

VFsymmetric

Back
Perkusi Front Back Auskultasi Front

VF symmetric
Sonor Sonor lost, Rhonci -/-,

BBS Vesicular, Rhonci -/-, BBS Wheezing -/-

Wheezing -/-

Back

BBS Vesicular, Rhonci -/-, BBS Vesicular, Rhonci -/-, Wheezing -/Wheezing -/-

Inspection

Looks iktus cardiac pulsation in ICS VI

Palpation

Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6

Right limit Percussion Left limit

ICS 4 linea right sternal

ICS 6, 2 finger lateral linea left midclavicularis

Auscultation

HS I reguler and HS II regular, murmur (+), Gallop (-)

Abdomen
Inspeksi: stomach looks flat

Palpasi:
LiverSpleen impalpable ; ball -/-; Pressure Pain ,Acites Auskultasi:

Perkusi: Tympani; Percussion Pain -

Bowel sound (+)

Upper Extremities
Kanan Muscle Tonus Normotonus Normotonus Kiri

Massa
Joint Move Power Akral Edema

Normal
in all directions in all directions +5 Warm -

Normal
in all directions in all directions +5 Warm 11

Lower Extremities

Kanan Muscle Tonus Massa Joint Move Power Akral Normotonus Normal in all directions in all directions +5 Warm

Kiri

Normotonus Normal in all directions in all directions +5 Warm

Edema

LABORATORIUM
HEMATOLOGI HASIL

Sunday/27 May 2013

NILAI RUJUKAN

Hemoglobin
Leukosit Hematokrit Trombosit
CLINICAL CHEMISTRY

13.7 g/dl
10,5ribu/UL 39,3 % 200ribu/uL HASIL

12-14 g/dL
5-10 ribu/UL 37-47 % 150-400 ribu/uL NILAI RUJUKAN

Ureum
Creatinin

15-45 mg/dl
0.70-1.10 mg/dl

LABORATORIUM
ELEKTROLIT HASIL

Sunday/27 May 2013

NILAI RUJUKAN

Natrium

- mmol/L

136-145 mmol/L

Kalium

- mmol/L

3.5-5.1 mmol/L

Clorida

- mmol/L

99-111 mmol/L

GULA DARAH SEWAKTU

-mg/dl

<200

Assessment
Acute tonsilopharyngitis Dd: Dengue High Fever

15

Therapy
Diit : normal food IVFD : III RL/24 hours MM/ : Paracetamol

16

Planning
Pro Home care Enough rest

17