critical skill

7/29/2019 Critical Skill

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Case for Analytic Skill

Feb 26th , 2013


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Name : ARP

Sex : Male

Age : 19 yo

Nationality: Indonesia

Occupation: Student

Religion : Moeslem

Address : Jl. Tukad Pancoran Kediri Tabanan

TC : 13.23 Wita

Patient Identity


3/14

Anamnesis

Chief complain : Fever

Patient has come with complaints of sudden

high fever since 5 days BATH. Fever wascontinuous but reduced after consuming feverdrug (paracetamol), but fever appeared again fewhours later.

Patient felt headache since 3 days BATH.Headache was felt along day and getting worsenwhen he did activities.


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Anamnesis

Patients also complained of having muscle and joint

pain.

No bleeding from the gums, petechia or epixtasis. Normal consistency and coloration of stool and

urination with normal frequency.


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Past illness history

No history of having the same complaint before.

History of asthma, hypertension, DM, and heart disease wasdenied by the patient.

Medication history

Paracetamol 3 x 500 mg for 3 days.

Family history

None of his family members have similar symptoms.

Social history

No neighbours have similar symptoms.

Smoking (-), alcohol (-)


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Appearance : Moderately ill

Level of conciousness : E4V5M6

Blood pressure : 120/80 mmHg

Temperatur axilla : 37OC

Pulse rate : 80x/min, reguler

Respiratory rate : 20 x/min

Weight : 50 kg

Height : 160 cm

BMI : 19,53 kg/m2

Physical Examination


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Status Present

Eyes : Anemia -/-, ict -/- PR +/+ IsokorENT : WNLNeck : Glands enlargement (-) JVP PR 0 cm H2OChest examination

HEART

Insp : ictus cordis not visiblePalp : ictus cordis not palpablePerc : UB: ICS II, RB: PSL D, LB: MCL SAusc : S1S2 single regular murmur (-)

LUNGInsp : symmetricalPalp : vocal fremitus N/NPerc : sonor/sonorAusc : Vesicular +/+; ronchi -/-; wheezing -/-

Physical examination


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Abdomen

inspection : distention (-)

auscultation : normal bowel soundspalpation : liver : unpalpable

: spleen : unpalpable

percussion : tymphani

Extremitieswarm + + edema - -

+ + - -tourniquet Test (+)


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Abdomen: Insp : distensi (-)

Ausc : Bowel sound (+) normal

Palp : H/L not palpable

tenderness(-)Ballotment (-)

Perc: Tympani (+)

Extremity: pitting edema , warm

Complete Blood Count (Feb 21st )

- -

- -

+ +

+ +

Parameter Result Unit Remarks Referencerange

WBC 3,3 103/L L 4,1 10,9

-Ne 1,12 51.70 % 103/L 2,5 7,5

-Ly 0.54 25.20 % 103/L 1,0 4,0

-Mo 0.47 21.60 % 103/L 0,1 1,2

-Eo 0.00 0.73% 10

3

/L 0,0 0,5-Ba 0.00 0.82% 103/L 0,0 0,1

RBC 5.28 106/L 4,00 5,20

HGB 15.60 g/dL 12,00 16,00

HCT 48.10 % H 36,0 46,0

MCV 82.50 fL 80,0 100,0

MCH 28.70 Pg 26,0 34,0

MCHC 34.80 g/dL 31,0 36,0

RDW 11.50 % 11,0 14,8

PLT 114 103/L L 150 440


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Abdomen: Insp : distensi (-)

Ausc : Bowel sound (+) normal

Palp : H/L not palpable

tenderness(-)Ballotment (-)

Perc: Tympani (+)

Extremity: pitting edema , warm

Complete Blood Count (Feb 22nd )

- -

- -

+ +

+ +

Parameter Result Unit Remarks Referencerange

WBC 3,16 103/L L 4,1 10,9

-Ne 1,12 51.70 % 103/L 2,5 7,5

-Ly 0.54 25.20 % 103/L 1,0 4,0

-Mo 0.47 21.60 % 103/L 0,1 1,2

-Eo 0.00 0.73% 10

3

/L 0,0 0,5-Ba 0.00 0.82% 103/L 0,0 0,1

RBC 5.28 106/L 4,00 5,20

HGB 16.30 g/dL H 12,00 16,00

HCT 49.60 % H 36,0 46,0

MCV 82.50 fL 80,0 100,0

MCH 28.70 Pg 26,0 34,0

MCHC 34.80 g/dL 31,0 36,0

RDW 11.50 % 11,0 14,8

PLT 60 103/L L 150 440


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ASSESSMENT

Susp. DHF gr. I (day 6)


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TREATMENT

Hospitalized

IVFD RL 30drips/min

Paracetamol 3 x 500 mg

Drink water 1,5-2 liters daily


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Pdx:Serologi DHF day VII

MonitoringVSComplaints

CBC @ 12 hours

PLANNING


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