Download - Yepyep New
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• Keluhan Utama :Demam sejak 2 hari SMRS
• Keluhan Tambahan :Bada pegal-pegal sejak 2 hari SMRS
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Riwayat Perjalanan Penyakit
2 hari SMRS OS mendadak demam (+) tinggi, dan turun (+) jika diberikan obat penurun demam, badan pegal-pegal (+) terutama pada sendi, kepala pusing (+), mual (+), muntah (-), sesak (-), nyeri dada (-), batuk (-), nyeri ulu hati (+) dibagian perut tengah atas, badan lemas (+), sempoyongan (-), BAK dan BAB tidak ada keluhan. Os tidak berobat dan hanya meminum 1 paracetamol tab jika demam terlalu tinggi.
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1 hari SMRS OS kembali mengeluhkan keluhan yang sama, demam (+) tinggi, menggigil (+), mual (+), muntah (-), sesak (-), nyeri dada (-), batuk (-), nyeri ulu hati (+) pada perut tengah atas, nyeri dibelakang bola mata (-), nyeri sendi (-), nyeri saat BAK (-), BAB tidak ada keluhan, nyeri menelan (-). OS hanya meminum paracetamol tab dan merasa tidak ada perbaikan, OS lalu berobat ke RSMH dan dirawat.
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Riwayat Penyakit Dahulu
• Riwayat darah tinggi (+) sejak 2 tahun yang lalu
• Riwayat kencing manis (-)• Riwayat mimisan (-)• Riwayat gusi berdarah (-)• Riwayat berpergian keluar kota beberapa
bulan terakhir (-)• Riwayat tinggal di daerah endemis malaria (+)
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Riwayat Penyakit Keluarga
• Riwayat penyakit dalam keluarga dengan keluhan yang sama (-)
• Riwayat keluarga yang terkena DBD (-)• Riwayat keluarga yang terkena malaria (-)
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Pemeriksaan Fisik
• Keadaan Umum :Sens : Compos mentisTD : 150/100 mmhgN : 85 x/mT : 38,30
CRR : 20 x/mTB : 155 cmBB : 55 kgBSS : 142 mg/dl55
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• Keadaan Spesifik :
1. Kepala :- Mata : Konjungtiva anemis (-) Sklera ikterik (-)- Hidung : Sekret (-) Deviasi septum (-) Konka anterior (-) Epistaksis (-)- Telinga : Sekret (-) Nyeri tarik aurikula (-) Nyeri tekan tragus (-) Nyeri tekan mastoid (-)- Mulut : Anemis (-) Lidah kotor (-) Faring hiperemis (-) Sariawan (-)
Stomatitis (-)
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2. Leher : JVP 5-2 CmH2O Pembesaran KGB (-)
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3. Thorax :a. JantungInspeksi : ictus cordis terlihatPalpasi : ictus cordis terabaPerkusi : - batas atas ICS II linea sternalis sinistra- batas kanan ICS IV linea parasternalis sinistra- batas kiri ICS V linea midclavicula sinistra Auskultasi : BJ I-II normal, reguler Murmur (-) Gallop (-)
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b. Paru-paru :Inspeksi : keadaan statis simetris
keadaan dinamis simetris sela iga tidak melebar
Palpasi : stemfremitus kanan = kiriPekusi : sonor pada kedua lapangan
paruAuskultasi : vesikuler (+) normal
rhonki (-) wheezing (-)
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• Abdomen : Inspeksi : datarPalpasi : lemas nyeri tekan (-) hepar dan lien tidak terabaPerkusi : tympani nyeri ketuk (-) asites (-) shifftingdulness (-)Auskultasi : Bising usus (+) normal
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• Genitalia : tidak diperiksa• Ekstremitas : Pucat (-)
Edema pretibia (-)
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• Rumple leed test (-)
Pemeriksaan Penunjang
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RONTGEN
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EKG
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Pemeriksaan Anjuran
• Cek DR• Urin Rutin• IgG dan IgM
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Diagnosis Banding
• Demam dengue + Hipertensi Grade II• Malaria + Hipertensi Grade II
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DIAGNOSIS
• Viral Infection + Hipertensi grade II
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Prognosis
• Vitam : dubia ad bonam• Fuctionam : dubia ad bonam• Sanationam : dubia ad bonam
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Penatalaksanaan
• Non Farmakologi :IstirahatDiet NBEdukasi
• Farmakologi :IVFD RL gtt XX/menitPCT 3x500mg/hariValsarfan 1x80mg/hari