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Findings Assessment Therapy Planning

- Fever with shivering- Tiredness - Nausea- vomitingBP : 120/70mmhgPR : 88x/minute, adequate, regularRR : 22x/minuteTemp : 38.50cThoraks : Heart : Ins : simetric Pal : VF simetric right and left Per : Right:sonor Left : sonor Aus : left : basic breath sound vesikulerRight : basic breath sound vesikuler

Abdoment :Ins : flat abdomentPal : depress pain (-) defence muskular (-) Per : timpani , perccusion pain (-)Aus : intestine noise 5 timesEdema (-)LAB FINDING:H2TL :Hb : 13,7 g/dlLeucosit : 10,5Trombosit 200Hematokrit 39,3

pharingytis DD : Dengue hemoragic

fever

Diit : normal food,

MM/ :Paracetamol 3x1

•Pro Home care• enough rest

Name : Mr Tunjung , 24 YOAddress : kp melati, pd gedeCC : fever with shivering

TC : friday/28 june 2013 /19:30CM

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Subjective DataName : : MR Tunjung ,24 YO

Address : : Kp Melati no 31 pd gede

CC : shivering with feverCM :

TC : Friday 28june 2013 /19:30

Anamnesis

Main Complaint

• Fever with shivering since 4 days before admittance

Additional Complaints

Disphagia, nausea

Autoanamnesis dan Alloanamnesis on the date 21 june 2013, Time

01.30 WIB

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AnamnesisPatient 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 (+)

04/20/23

Past Medical History and Treatment

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

Family History (-)Social History

Smoking (-) , Alcohol (-)

Objective DataAppearance : moderate

illness

awareness : E4V5M6;

CM

TD : 120/80mm

Hg

HR : 88x /menit

(adequate, reguler)

RR : 22x /menit

Temp : 38,5°C

Objective Data Head :Normocephali

Konjunctiva anemic -/-

Sklera Ikterik -/-

JVP : 5-2 cmH2O

pharynx : hyperemis (+)Tonsil : T2/T2

ThoraxPulmonal Left Right

Inspeksi FrontStatic and dynamic symmetric Static and dynamic symmetric

backStatic and dynamic symmetric Static and dynamic symmetric

Palpasi Front VF symmetricVFsymmetric

BackVF symmetric VF symmetric

Perkusi Front Sonor Sonor

Back Sonor Sonor

Auskultasi Front BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS lost, Rhonci -/-,

Wheezing -/-

Back BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS Vesicular, Rhonci -/-,

Wheezing -/-

Inspection Looks iktus cardiac pulsation in ICS VI

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

Percussion

Right limit ICS 4 linea right sternal

Left limit ICS 6, 2 finger lateral linea left midclavicularis

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

Abdomen

Inspeksi:

stomach looks flat

Palpasi:

Liver–Spleen impalpable ; ball -/-;Pressure Pain ,Acites -

Perkusi:

Tympani; Percussion Pain -

Auskultasi:

Bowel sound (+)

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Upper Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

Lower Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

LABORATORIUM

HEMATOLOGI HASIL NILAI RUJUKAN

Hemoglobin 13.7 g/dl 12-14 g/dL

Leukosit 10,5ribu/UL 5-10 ribu/UL

Hematokrit 39,3 % 37-47 %

Trombosit 200ribu/uL 150-400 ribu/uL

CLINICAL CHEMISTRY HASIL NILAI RUJUKAN

Ureum - 15-45 mg/dl

Creatinin - 0.70-1.10 mg/dl

Sunday/27 May 2013

LABORATORIUM

ELEKTROLIT HASIL 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

Sunday/27 May 2013

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Assessment

Acute tonsilopharyngitisDd: Dengue High Fever

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TherapyDiit : normal foodIVFD : III RL/24 hours MM/ :Paracetamol

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Planning•Pro Home care•Enough rest