24 maret lapjak
TRANSCRIPT
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DUTY REPORT
MARCH 24th 2016
Doctor on duty : dr. ge y dr nurchenCo!"" on duty : #u$%u" & O't!r%
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(!nt!% )(!nt!% 4
Tn E "u"* *eny!'%t !uto%+un,y D dengue -e er
Tn A /e$u$%t%"
(!nt!% ,Y H d%! ete" 'eto"%"
(!nt!% 6 Tn. Tn DH gr!de 1 Tn R DH gr!de 1
Re'!*%tu$!"% P!"%en
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,!+! : Tn.
#3 : (!'% $!'%
U+ur : 0 T!hun
Ag!+! : "$!+
,o RM : 52 5 7
Tg$ MR/ 24 M!ret 8 *'. 02.00 9
. DE,T TA/ PA/ E,
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1. A,AM,E/ / ;Auto!n!+ne"%"<
3e$uh!n Ut!+! : De+!+ "e=!' 6 h!r% y!ng $!$u
. DATA DA/AR
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P!"%en d!t!ng deng!n 'e$uh!n de+!+ t%ngg% "e=!'6 h!r% "+r". De+!+ d%r!"!'!n "e*!n=!ng h!r% d!n"e+!'%n *!n!". P!"%en t%d!' *ern!h +engu'ur"uhuny!. De+!+ turun %$! +%nu+ o !t*!r!cet!+o$8 n!+u+ n!%' 'e+ !$%. De+!+d%r!"!'!n d%"ert!% +eng%g%$
Pu"%ng ;>
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RPD
H%*erten"% ; <
DM ; <
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R%?!y!t *eny!'%t $%ng'ung!n
Tet!ngg! *!"%en !d! y!ng d%r!?!t deng!n 'e$uh!n
y!ng "!+!
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RPO
*!r!cet!+o$
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2. PEMER 3/AA, / 3
PEMER 3/AA, UMUM3e!d!!n U+u+ : T!+*!' "!'%t "ed!ng3e"!d!r!n : Co+*o" +ent%"
: 6 'g T : 16 c+ Te'!n!n D!r!h : 100@ 5 ++Hg,!d% : 0 @+nt8 %regu$er
RR : 22 @+nt/uhu : )58) BC
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/TATU/ E,ERA( /
3e*!$! : ,or+oce*h!$
R!+ ut : ?!rn! h%t!+8 d%"tr% u"% +er!t!
9!=!h : "%+etr%"8 de-or+%t!" ; <M!t! : 'on=ungt% ! *uc!t @ 8 "'$er! %'ter%'
@ 8 +!t! ce'ung ; @
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Thoraks
ParuInspeksi : entu' d!d! nor+!$8 ger!'
d!d! "%+etr%" "!!t "t!t%" d!n d%n!+%"8 8
retr!'"% %nterco"t!$ ; <Palpasi : t!'t%$ -re+%tu" 'edu! *!ru
"%+etr%"8 che"t e *!n"%on "%+etr%"8 nyer%
te'!n ;
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Jantung
Inspeksi : %'tu" 'ord%" t%d!' ter$%h!t
Palpasi : %'tu" 'ord%" ter! ! d% C/ !g!'+ed%!$ 2c+ d!r% (%ne! +%dc$! %cu$!r%" "%n%"tr!
Perkusi
!t!" '!n!n =!ntung : C/ $%ne! *!r!"tern!$%"de tr!
!t!" '%r% =!ntung : C/ $%ne! ! %$$!r%" !nter%or"%n%"tr!
!t!" *%ngg!ng =!ntung : C/ $%ne! *!r!"tern!$ '%r%
Auskultasi : # @ %rregu$er8 +ur+ur ; < g!$$o* ;F<
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Abdomen
Inspeksi : tampak datar
Auskultasi : bising usus (+) normal
Palpasi : turgor baik
Perkusi : timpani pada seluruh kuadran abdomennyeri tekan (-),
Ekstremitas : akral hangat, CRT < 2 “, edema (-), rumpleleed (+)
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). PEMER 3/AA, PE,U,#A,
JenisPemeriksa
an
Hasil Nilai Rujukan24/03/2016
He+og$o %n 17.3 1) 15 g@d(He+!to'r%t 51 40 2 G
Er%tro"%t . 1 48) 680 =ut!@I((eu'o"%t 31 0 4.500
10.500@I( Tro+ o"%t 5 000 1 0.000
400.000@I(Ant% dengue%g
neg!t% e neg!t% e
Ant% dengue%g M
*o"%t% e neg!t% e
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P!"%en $!'% $!'% 2 t!hun d!t!ng deng!n 'e$uh!nde+!+ 6 h!r% "+r". De+!+ t%+ u$ +end!d!'d!n "e*!n=!ng h!r% y!ng d%r!"!'!n "e+!'%nt%ngg%. De+!+ d%"ert!% +eng%gg%$8 *u"%ng8 nyer%"end%8 +u!$8 !tu' *%$e'
Ht 1 G
Tro+ o"%t 5 .000
(eu'o"%t )150
Ant% dengue %g M ;><
. R , 3A/A,
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1. De+!+ erd!r!h Dengue gr!de 1
. DA TAR MA/A(AH
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D%"cu""%on
+u!$
De+!+ 6 h!r% ;+en%ng'!t d!n d%r!"!'!n "e*!n=!ng h!r%<
D!r% !n!+ne"%" d!n *e+er%'"!!n J"%' d%d!*!t'!n de+!+ +end!d!'d!n t%ngg%8 nyer% "end%
,yer% "end%
Torn%7uet te"t ;><
Tro+ o"%to*en%! d!n he+o 'on"entr!"%
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Sudden high fever
Viral infection
Stimulated bleeding
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Platelets 87.000
Platelets should be increase
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Dengue -e er gr!d%ng
r!de : e er ?%th unty*%c!$ con"t%tut%on!$ "y+*to+"8$eed%ng +!n%-e"t!t%on ;>< y tourn%7uet te"t
r!de : r!de ?%th "*ont!neou" $eed%ng
r!de : Co+*en"!ted D// ;ch!r!cter% ed y t!chy orr!dyc!rd%! or hy*oten"%on8 ?%th co$d "'%n !nd
!g%t!ted<
r!de :Unco+*en"!ted D// ;ch!r!cter% ed y %rregu$!r$ood *re""ure !nd "he!rt r!te<
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P$!n !nd Tre!t+ent,on *h!r+!co$og%c!$%nter ent%on":
ed re"tOr!$ Ku%d %nt!'e +! .
2(@d!yPh!r+!co$og%c!$%nter ent%on":
D A"er%ng )0 t*+Ant%*%ret%' P!r!cet!+o$ 00 +g;*rn<R!n%t%d%ne 2 1 !+*
Diagnostic plans:DPL/24 jam
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Progno"%"Luo !d %t!+ : !d on!+
Luo !d unct%on!+ : !d on!+Luo !d /!n!t%on!+ : !d on!+
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THA,3 YOU