Critical Skill
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Transcript of 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
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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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