Case report

• Nama : Tiara • Umur : 3 tahun 6 bulan• Jenis Kelamin : Perempuan• RM : 00.54.96.71• Alamat : Desa Gunung Lagan

Kec. Gunung M• Tanggal Masuk: 26 Februari 2013

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Keluhan Utama : Penurunan Kesadaran

Telaah : Hal ini dialami os sejak 9 jam sebelum masuk rumah sakit. Pasien mengalami kecelakan. Pasien tertimpa buah kelapa yang jatuh dari pohonnya. Os juga sudah dibawa ke rumah sakit.

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oPemeriksaan UmumoKesadaran : GCS 8 (E2M2V2)oTekanan darah : 110/40 mmHgoNadi : 130 x/menitoSuhu : 36,5 CoPernafasan : 40 x/menitoKeadaan Umum : BurukoKeadaan Gizi : Sedang

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Primary Survey :Airway : Stridor, dilakukan pemasangan

Orofaringeal TubeBreathing : Circulation :Disability :

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o Secondary Survey :o

Physical examinationGeneralized status

Body weight: 21 kg, Body length: 128 cm, Body weight in 50th percentile according to age: 30 kgBody length in 50th percentile according to age: 136 cmBody weight in 50th percentile according to body

length: 26 kg

BW/BL: / x 100% = 80,7% BW/age: / x 100% = 70 % BL/age : / x 100% = 94,11 %

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Presence Status : Sensorium: GCS 13 (E4V4M5), Temperature: 35C. Anemic (-), dyspnea (-), cyanotic (-), edema(-), icteric (-). Body weight (BW): 20 kg. Body length (BL): 128 cm. CDC: BW/Age = 70%, BL/Age =

94,11%, BW/BL = 80.7%

Localized status• Head :Eye: light reflex (+/+), isochoric pupil, pale inferior

conjunctiva palpebra (-/-). Ear: within normal limit. Nose: naso gastic tube (+), blood (+). Mouth: dry

mouth(+).• Neck : Lymph node enlargement (-), neck stiffness (-)

• Chest :Symmetrical fusiform, epigastrial retraction(-),HR: 152 bpm, regular, murmur (-) RR : 38 x/minute,

regular, ronkhi (-/-). 8

• Abdomen : Soepel (+), peristaltic (+), hepatomegaly (+) 4 cm BAC, spleen not palpable.

• Extremities : Pulse : unpalpable, blood

pressure: unmeasured, clubbing finger (-), BCG scar (+) right arm, decrease of subcutaneous fat .

• Ano-Genitalia : Male, within normal limit and anus (+).

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Parameters Result Normal Value Unit

Complete Blood Count

Hemoglobin (Hb) 10.6 12 – 14.4 g %

Erytrocyte (RBC) 3.55 4.40 – 4.48 106/mm3

Leukocyte (WBC) 14.62 4.5 – 13.5 103/mm3

Hematocrite 27.50 37 – 41 %

Trombocyte (PLT) 19 150 – 450 103/mm3

MCV 77.50 81 – 95 fL

MCH 29.90 25 – 29 pg

MCHC 38.50 29 – 31 g %

RDW 13.00 11.6 – 14.8 %

Neutrophil 44.90 37 – 80 %

Limphocyte 23.60 20 – 40 %

Monocyte 30.20 2 – 8 %

Eosinophil 0.00 1 – 6 %

Basophil 1.300 0 – 1 %

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Neutrophil Absolute 6.57 2.4 – 7.3 103/µL

Limphocyte Absolute 3.45 1.7 – 5.1 103/µL

Monocyte Absolute 4.41 0.2 – 0.6 103/µL

Eosinophil Absolute 0.00 0.10 – 0.30 103/µL

Basophil Absolute 0.19 0 – 0.1 103/µL

Carbohydrate

Metabolism

Glucose 70.70 < 200 mg/dL

Working Diagnosis:• Dengue Shock Syndrome

Management: • IVFD RL 20 ml/kgBW = > 400 cc bolus

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Follow UpDecember 27th 2012

S Blood in NGT (+), apatis (+)

O Sens: GCS 14 (E4V4M5), Temp: 36,5°C,

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit.

Nose: blood in NGT (+), nasal canule (+)

Mouth: dry mouth

Neck : Lymph node enlargement (-), neck stiffness (-)

Chest : symmetrical fusiform,

HR: 116 bpm, regular, murmur (-)

RR : 24 x/minute, regular, ronkhi (-)

Abdomen : Soepel (+), peristaltic (+), liver can be palpable 4 cm under arcus costa

Extremities : Pulse = 116 bpm, regular, adequate pressure/volume, blood pressure: 80/40, clubbing finger (-).

Ano- Genital : Male,

A Dengue Hemorragic Syndrome Grade III

P Management:

-O2 1 liter/nasal canule

-IVFD 2 line 10cc/kgBW

I: RL 5 cc/kgBW = 25 gtt/I (macrodrip)

II: HES 5 cc/kgBW = 100 gtt/I (microdrip)

-PCT 3x 250 mg

-Inj. Ranitidine 20mg/8h/iv

-Fasting

R/ - Consult to Infection and Tropic disease Division

- Check complete blood count/6hours

- Transfusion whole blood

WB requirement: 6x20 x ( 11-6.9) = 492cc

Transfusion ability: 5x 20: 100cc 13

Consult results from Infection and Tropic Disease Division (December

27th 2012 )Working Diagnosis: Dengue Shock Syndrome Advice:– Check CBC/6h– Rontgen thorax PA– Check Liver function test– Fluid: 3 cc/kgBW/h (adjust to hemodynamic

state)– Monitoring blood pressure, HR, RR,

temperature and urine output.14