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  • Identitas: Nama Usia Jenis Kelamin Alamat Tanggal Masuk RS: 12 September 2018

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    This document contains information about a 14-year-old male patient admitted to the hospital with a chief complaint of fever for 1 month. On examination, the patient appeared sick but stable, with normal vital signs including a temperature of 40.1°C. Laboratory tests were ordered along with IV fluids and antibiotics. The initial working diagnosis was typhoid fever.

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    An. a, Tifoid, 12 Sept 2018

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    This document contains information about a 14-year-old male patient admitted to the hospital with a chief complaint of fever for 1 month. On examination, the patient appeared sick but stable, with normal vital signs including a temperature of 40.1°C. Laboratory tests were ordered along with IV fluids and antibiotics. The initial working diagnosis was typhoid fever.

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    3 views5 pages

    Identitas: Nama Usia Jenis Kelamin Alamat Tanggal Masuk RS: 12 September 2018

    Uploaded by

    laydy
    This document contains information about a 14-year-old male patient admitted to the hospital with a chief complaint of fever for 1 month. On examination, the patient appeared sick but stable, with normal vital signs including a temperature of 40.1°C. Laboratory tests were ordered along with IV fluids and antibiotics. The initial working diagnosis was typhoid fever.

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    © All Rights Reserved
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    of 5

    IDENTITAS

    Nama : An. A
    Usia : 14 tahun
    Jenis Kelamin : Laki-laki
    Alamat : Muara Angke
    Tanggal Masuk RS : 12 September 2018
    KELUHAN UTAMA

    Demam sejak 1 bulan SMRS


    PEDIATRIC ASSESMENT TRIANGLE
    • Appearance (TICLS)
    – Tonus : adekuat
    – Interactiveness : sadar
    – Consolability : dapat ditenangkan
    – Look or Gaze : adekuat
    – Speech and Cry : ada
    • Breathing
    Pola napas normal, retraksi (-)
    • Circulation
    Kulit pucat (-), mottled skin (-)

    Kesan -> Tidak Terdapat Kegawatdaruratan


    PRIMARY SURVEY
    Nilai Normal
    • Airway RR: 12-18 x/menit
    – Clear HR: 60-100 x/menit
    • Breathing
    – Laju napas: 22 x/menit
    – Pola napas normal, retraksi (-)
    • Circulation
    – Tekanan darah: 130/80 mmHg
    – Laju nadi: 118x/menit, reguler, teraba kuat penuh
    – Suhu: 40,1 ºC
    – Akral hangat, CRT <2 detik
    Kesan  Tidak terdapat kegawatdaruratan
    JAM KLINIS TATALAKSANA

    12:00 Keadaan Umum: tampak sakit sedang • IVFD RL 1500 cc/24 jam
    Kesadaran: compos mentis (E4M6V5) • Paracetamol 500 mg IV
    TD: 130/80 mmHg • Cek DL, Diff count, elektrolit,
    HR: 118 x/menit, nadi teraba kuat penuh Widal
    RR: 22 x/menit
    Suhu: 40,1 °C
    BB: 45 kg
    Abdomen : supel, nyeri tekan at regio
    lumbal sinistra

    13:20 Keadaan Umum: tampak sakit sedang Konsul dr. Susilawati, Sp.A, atas
    Kesadaran: compos mentis (E4M6V5) indikasi beliau:
    TD: 130/80 mmHg Rawat dalam bangsal
    HR: 100 x/menit, nadi teraba kuat penuh IVFD D51/2NS 1500ml/24jam
    RR: 22 x/menit Diet lunak
    Suhu: 39,7 °C Ceftriaxone 2x1gram IV drip dalam
    BB: 45 kg D5% 100 ml selama 30 menit
    Abdomen : supel, nyeri tekan at regio Ranitidine 3x40mg IV
    lumbal sinistra Paracetamol 500mg PO/4jam
    Cek kultur darah, CRP, UL, FL,
    Benzidine test
    DIAGNOSIS KERJA AWAL
    Typhoid fever (A01.00)

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