DUTY REPORT

SUNDAY MORNING, APRIL 10th 2011

New Patients : Patients

Consultation : DHF :
Out patients : Non DHF :
Refused adm :-
Dead case :
 Team In Charge

Consultants
1. dr. , SpPD
2. dr. ,SpP(K)

Team
I : dr. / dr.
dr. / dr.
II A : dr.
II B : dr.
II C : dr.
III : dr.
II B
DHF PATIENTS
1. , , yo CM :
Jln. TC :
chief complain :

Assessment Therapy Planning

• Prob DHF grade I - Adm  Pl/
(days ) - Free diet Serology DHF( D7)
- IVFD RL 30 d/min
- Paracetamol 500 mg tab
- IEC Monitor
• VS (BP, HR, RR, tax)
• Complain
• Fluid balance
• CBC @ 12 hours
WBC :
Hb :
Ht : :
PLT :
2. , , yo CM :
Jln. TC :
chief complain :

Assessment Therapy Planning

• Prob DHF grade I - Adm  Pl/
(days ) - Free diet Serology DHF( D7)
- IVFD RL 30 d/min
- Paracetamol 500 mg tab
- IEC Monitor
• VS (BP, HR, RR, tax)
• Complain
• Fluid balance
• CBC @ 12 hours
WBC :
Hb :
Ht : :
PLT :
3. , , yo CM :
Jln. TC :
chief complain :

Assessment Therapy Planning

• Prob DHF grade I - Adm  Pl/
(days ) - Free diet Serology DHF( D7)
- IVFD RL 30 d/min
- Paracetamol 500 mg tab
- IEC Monitor
• VS (BP, HR, RR, tax)
• Complain
• Fluid balance
• CBC @ 12 hours
WBC :
Hb :
Ht : :
PLT :
4. , , yo CM :
Jln. TC :
chief complain :

Assessment Therapy Planning

• Prob DHF grade I - Adm  Pl/
(days ) - Free diet Serology DHF( D7)
- IVFD RL 30 d/min
- Paracetamol 500 mg tab
- IEC Monitor
• VS (BP, HR, RR, tax)
• Complain
• Fluid balance
• CBC @ 12 hours
WBC :
Hb :
Ht : :
PLT :
5. , , yo CM :
Jln. TC :
chief complain :

Assessment Therapy Planning

• Prob DHF grade I - Adm  Pl/
(days ) - Free diet Serology DHF( D7)
- IVFD RL 30 d/min
- Paracetamol 500 mg tab
- IEC Monitor
• VS (BP, HR, RR, tax)
• Complain
• Fluid balance
• CBC @ 12 hours
WBC :
Hb :
Ht : :
PLT :
CDC, WHO, 2009
CDC, WHO, 20
CDC, WHO, 20
CDC, WHO, 20
Fluid management in susp.DHF in ward

Need of cristalloid volume:

1500 + 20 x (KgBW – 20)
Example maintenance fluid for 55 Kg BW:
1500 + 20 x (55-20) = 2200 ml
Monitoring according to clinical condition

Pan American Health Organization: Dengue and Dengue

Hemorrhagic Fever: Guidelines for Prevention and Control.
PAHO: Washington, D.C., 1994: 67.
Fluid management for DHF with HCT increased >20%

Need of fluid/day= fluid deficit + maintenance

5% BW deficit = 5% x BW
Example for 60 Kg BW:
5% deficit = 5% x 60 x 1000 ml = 3000 ml
Maintenance = 1500 + (20 x 40)= 2300 ml
Fluid volume / day = 5300 ml/24 hours

Adjusting fluid volume according to clinical conditions

Evaluation of vital sign every hour , HCT every 4 hour
Protokol 3. DBD dg perdarahan spontan/masif, tanpa syok
Protokol 4.
Penatalaksanaan DBD dws dgn syok dan tanpa perdarahan
spontan
Protokol 5.
Penatalaksanaan
DBD dws dgn
syok dan
perdarahan masif
NON DHF PATIENTS
1. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
2. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
3. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
4. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
5. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
6. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
7. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
8. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
9. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
10. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
11. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
12. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
13. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
14. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
15. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
16. , , yo CM :
Jl. TC :
CC :

Assessment Therapy Planning

- Adm  P/
- NS 20 gtt / min - N

- POC days
Mx/
- Vital Sign
- Complaints
Chest X-Ray
BOF
ECG
CASE PRESENTATION
 Identity
Name :
Gender :
Age : yo
MR : :
Ward :
TC :
Chief complain :
Address :
Present Medical History
Past Medical History
No history of liver Ds

Family History
No other family have

Social History
Patient was obese and lack exercise
PHYSICAL EXAMINATION
LOC : E4V5M6
App : moderately ill
Temp : 36.5 ºC
BP : mmHg
PR : x/mnt regular
RR : x/min.
Pain score : /10

Eye : An -/-, Ict -/-

ENT : PR + 2 cm H20
Neck : Lymphnode enlargement (-)

Thorax
Heart
Insp : IC Unseen
Palp : IC palpable at 1 cm medial MCL (S), ICS V
Perc :
Right border : PSL (D)
Left border : MCL S
Ausc : S1 S2 single, regular, murmur ( - )
Lung
Inspection : Simmetric on static and dynamic
Palpation : VF N/N
Percussion : sonor/sonor
Auscultation : Ves + /+, Rhonci -/-, Wheezing
-/-

Abdomen
Inspection : Distended (-)
Auscultation: Bowel sound ( + ) N
Palpation : tenderness (+) at hipokondrium dextra
liver : 4 cm bac, 4 cm bpx, obtuse
angle, unregular border, nodulated, pain on
palpation, hard consistency , fixed, bruit (-)
spleen : unpalpable
mass at lower abdoment (-), defance musculer
(-)
Percussion : tympanic
Inguinal limphonody enlargement (-)
Extremities
CBC
WBC
Neu (%)
Lym (%)
Mo (%)
Eo (%)
Ba ( %)
HB
HCT
MCV
MCH
PLT
 ALT AFP

AST HbsAg

BUN Anti HCV

SC

BS

Bil Tot

Bil Dir Na

ALP K

GGT

ALbumin

Globulin
 UL
PH 6,0
Leukosit (-)
Nitrite (-)
Protein
Glukosa
Ketone
Urobilinogen
Bilirubin
Eritrosit
Colour
Sedimen
Leko
Eri
BGA
Ph
PCO2
PO2
HCO3
BE
SO2
Na
K
Chest X-Ray
BOF
ECG
USG Abdomen
Picture of patient
Assesment
 Therapy
 IVFD NaCl 0,9% 20 dpm
 Planning
P/
 USG
Mx/
 Vital sign
 Complain
 OBSERVATION CHART
S O A P

Pain decreased CM • Prob IVFD NaCl 0,9% 20

T 100/70 dpm
06.05 RR 20x Diet 2100 kcal
RUQ: tenderness (+)
Defance musculer (-)
 OBSERVATION CHART
S O A P

Pain decreased CM • Prob IVFD NaCl 0,9% 20

T 100/70 dpm
06.05 RR 20x Diet 2100 kcal
RUQ: tenderness (+)
Defance musculer (-)
 OBSERVATION CHART
S O A P

Pain decreased CM • Prob IVFD NaCl 0,9% 20

T 100/70 dpm
06.05 RR 20x Diet 2100 kcal
RUQ: tenderness (+)
Defance musculer (-)
 OBSERVATION CHART
S O A P

Pain decreased CM • Prob IVFD NaCl 0,9% 20

T 100/70 dpm
06.05 RR 20x Diet 2100 kcal
RUQ: tenderness (+)
Defance musculer (-)
Thank you