MORNING REPORT

Joint pain .Fever for 3 days . T .Ptechiae in lower arm . minced food non stimulant • Sanmol drip 2x1 (iv) • OMZ drip 1x1 (iv) • Imboost forte (PO) 2x1 • • • • Assessment • Dengue Hemorhagic fever grade 1 with no hemoconcentration Planning DPL SGOT SGPT UL HCG . no:23 WD: DHF Findings .Heighten fever overtime .Nausea. 29 yo Manunggal.Mrs. vomited once CM : 256286 TE : monday 18/03/2013 Therapy • IVFD : Ringer Laktat + 1 amp Neurobion / 24 hr • Tim rice .

Subjective Data Name Age : Mrs Tina Mariana : 29 Yo Address : Manunggal no:23 CM : 256286 TE : Adm : Triage CC : High fever .

Anamnesis Patient came with high temperature fever for 3 days . The patient took Paracetamol on the 1st day and it .

Kidney disease (-) • Family History No family member has the same disease • Social History Employee (-) .• Past Medical History and Treatment HTN (-) . smoking (-) . Alcohol (-) . DM (-) .

. Rh -/. gallop (-) . CM Appearance :moderate ill BP : 120/80 mmHg PR : 104 x/min Temp : 36°C RR : 32 x/min EYE : anemic conjungtiva -/.Objective Data LOC : E4V5M6 . icterik -/ENT : pharyngeal hyperemis (-). murmur (-) . Wh +/+ 1st and 2nd heart sound normal ..secretion (-) THORAX : THORAX : Ins : chest wall movement symmetric Pal : vocal fremitus symmetric left and right Per : sonor symmetric left and right Aus : basic breath sound ekspirium elongated .

ABDOMEN Insp: abdomen looks flat Ausc : Bowel sound (+) 3x /minutes Pal : supple. capirally refill < 2 second . cold (-) . pain tap (-) EXTREMITIES Edema (-) . tenderness (-) Per : tympani.

2 g/dl Ht : 35.LABORATORY DATA Hb : 12.1 % Trombosit: 334000/ul Leukocyt : 12000/ul .

Assessment Asthma bronkiale mild persistent .

Therapy • Face mask 10 lpm • Inhalation : fulmicort 1amp + fentolin 1 amp • IVFD : I Rl + aminophilin 1 amp • II Rl 24 hours • Diet : rice tim • Mm/: • Ceftriaxone 2 x 1 gram • Dexamethasone 2 x 1 • OBH 3 x 1 c • Ranitidine 2x1 amp .

Planning • • • • complete peripheral blood Prick test Spirometri Rontgen thoraks .

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