24 Maret Lapjak

8/18/2019 24 Maret Lapjak

1/23

DUTY REPORT

MARCH 24th 2016

Doctor on duty : dr. ge y dr nurchenCo!"" on duty : #u$%u" & O't!r%


2/23

(!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


3/23

,!+! : 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,


4/23

1. A,AM,E/ / ;Auto!n!+ne"%"<

3e$uh!n Ut!+! : De+!+ "e=!' 6 h!r% y!ng $!$u

. DATA DA/AR


5/23

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 ;>


6/23

RPD

H%*erten"% ; <

DM ; <


7/23

R%?!y!t *eny!'%t $%ng'ung!n

Tet!ngg! *!"%en !d! y!ng d%r!?!t deng!n 'e$uh!n

y!ng "!+!


8/23

RPO

*!r!cet!+o$


9/23

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


10/23

/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 ; @


11/23

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 ;


12/23

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<


13/23

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 (+)


14/23

). 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


15/23

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,


16/23

1. De+!+ erd!r!h Dengue gr!de 1

. DA TAR MA/A(AH


17/23

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!"%


18/23

Sudden high fever

Viral infection

Stimulated bleeding


19/23

Platelets 87.000

Platelets should be increase


20/23

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<


21/23

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


22/23

Progno"%"Luo !d %t!+ : !d on!+

Luo !d unct%on!+ : !d on!+Luo !d /!n!t%on!+ : !d on!+


23/23

THA,3 YOU

24 Maret Lapjak

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