L-30

7 JUNE 2019
 Mr. Khoirul Anam : ALO
 Ms. Rika : Dengue fever
 Mrs.Juwariyah: DM tipe 2, Hipokalemi, RBBB,
 Mr.Kadimin : Acute Coronary Syndrome
 Mrs. Nurhayati : OF
 Mrs. Sriweni : GEA
 Mrs. Aishatun : GEA, hipokalemi
 Mr.Slamet : CHF
 Mrs. Musanah : Hypertension Essensial, Dyspepsia
 Mr.Rifai : GEA
 Mr.Nurul Fadli : ISPA
 Mr. Supriono : DM tipe 2
 Mrs.Mutiah : Observasi Febris
 Mr.Subekan: CHF
 Mr.Kasrip : GEA
 Mr.Suminten : LBP, Melena
 Name : Ms.R
 Age : 16 yo
 Address : Lamongan
 Date of examination: June 7 th , 2019
 Chief complain:
patients come to the emergency room with
complaints of fever. fever since 4 days ago.
fever falls after being given medication. the
patient also feels headache, atralgia, nausea
and vomiting since 4 days ago. Vomiting 5
timestoday. Patients also appear bleeding
spots 4 days ago in her hands. patients also
complain of abdominal pain and patients also
complain of pain swallowing today. nasal
bleeding (-), gum bleeding (-)
 Previous Illness History: never felt like this
 Familly Illness History : no family is sick like
this
 GCS 456
 BP: 119/74 mmHG
 Pulse rate:113x/minutes
 RR: 22x/minutes
 Temp: 37,9 C
 A: clear, gargling (-), snoring (-), speak
fluently (+), potential obstruction (-)
 B: spontan, RR 22x/mnt, ves/ves, Rh -/-, Wh
-/-, SaO2 98% without O2 support
 C: warm dry red, CRT <2”, PR 113x/mnt, BP
119/74 mmHg
 D: GCS 456, lateralization -, Round Isochoric
eyes 3mm/3mm
 E: temp 37,9 C
 General Status:
 GCS: 456
 H/N : a/i/c/d : -/-/-/-
 Thor:
 Pulmo: Symmetrical, rh -/-, wh -/-
 Cor: S1 S2 tunggal, mur-mur (-), gallop (-)
 Abd: unpalpable hepar and spleen, tymphany
 Extremities:
 Anemis: -|- Edema: -|-
 Eritrosit 4.14 ( 3.80 - 5.30 )
 Hemoglobin 12.3 ( 13.0 - 18.0 )
 Limposit 16.7 ( 25.0 - 33.0 )
 Basofil 0.4 ( 0.0 - 1.0 )
 Eosinopil 0.4 ( 1.0 - 2.0 )
 Hematokrit 37.2 ( 35.0 - 47.0 )
 Lekosit 2.5 ( 4.0 - 11.0 )
 MCH 29.70 ( 28.00 - 36.00 )
 MCHC 33.10 ( 31.00 - 37.00 )
 MCV 89.90 ( 87.00 - 100.00 )
 Monosit 10.3 ( 3.0 - 7.0 )
 MPV 7 ( 5 - 10 )
 Neutropil 72.2 ( 49.0 - 67.0 )
 RDW 10 ( 10 - 16 )
 Trombosit 47 ( 150 - 450 )
 SGOT 181 ( 0 - 35 )
 SGPT 182 ( 0 - 35 )
 Gula Darah Acak 131 ( )
 Woman , 16 yo
 fever since 4 days ago
 headache, atralgia, nausea and vomiting
 appear bleeding spots
 abdominal pain
 pain swallowing
 Temp: 37,9 C
 Leukopenia
 Trombositopeni
 SGOT 181
 SGPT 182
 Dengue fever
 Faal Coagulation
 Inf RL loading 1000cc  maintenance
1500cc/24 jam
 Inj. Tamoliv 3x1g iv
 Inj. Panloc 1x40mg iv
 General status
 Vital sign
 Patient complaints
 Lab : Trombosit, leukosit, SGOT, SGPT, Faal
coagulation

 Explain to patients and her family about :
disease, therapy, complication and
prognosis