MORNING REPORT

Mrs. T , 29 yo Manunggal, no:23 WD: DHF Findings

- Fever for 3 days - Heighten fever overtime - Ptechiae in lower arm - Joint pain - Nausea, vomited once

CM : 256286 TE : monday 18/03/2013 Therapy

IVFD : Ringer Laktat + 1 amp Neurobion / 24 hr Tim rice , 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

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

 Past Medical History and Treatment

HTN (-) ; DM (-) ; Kidney disease (-)

Family History
No family member has the same disease

Social History
Employee (-) , smoking (-) , Alcohol (-)

Objective Data
LOC : E4V5M6 ; CM Appearance :moderate ill BP : 120/80 mmHg PR : 104 x/min Temp : 36C RR : 32 x/min EYE : anemic conjungtiva -/- ; icterik -/ENT : pharyngeal hyperemis (-),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 ; Rh -/- ; Wh +/+ 1st and 2nd heart sound normal ; murmur (-) ; gallop (-)

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

LABORATORY DATA
Hb : 12.2 g/dl Ht : 35.1 % 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