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IA : dr. Mecy, dr. Rusyda, dr.Supono IB : dr. Amel, dr. Vindrya II : dr. Maya III: dr. Sri Sunarti, SpPD
Pulse Rate
Respiration rate T ax Head Neck Chest Heart
66 bpm, reguler
20 tpm 36,5 0C Anemic (-), Icteric (-) JVP R + 3 cmH2O at 45 0 Ictus invisible, palpable ICS V MCL S RHM SL (D), LHMIctus S1 S2 single , murmur Symetric SF D=S , V V V V V V Rh - --Wh - --S/S S/S S/S
Lung
Abdomen Extremities
Slight distended, BS (+) N, Liver span 12 cm, unpalpable, traube space dullness Edema - / -
Laboratory finding
Leucocyte Hemoglobine PCV Trombocyte RBS 5800 9.9 /l gr/dl
Value
N: 3.500 10.000 N: 11,0 16,5
28
22.000 35.6 0.62 22 20 137 3.56 107 Plasmodiu m Vivax
%
/L mg/dl mg/dL mg/dL
35 - 50
150.000 390.000 < 200 10-50 0,7 1,5 11 41 10 41 3,5 5,5 136 145 3,5 5,0 98 106
Ureum
Creatinine SGOT
U/L
U/L g/dl Mmol / L Mmol / L Mmol / L
SGPT
Albumine Na K Cl Blood Maal
CHEST X RAY
AP position, symetric, KV enough, less inspiration, trachea in the middle, soft tissue and bone normal. Phrenico costalis angle D sharp and S covered by cardiac shadow, Hemidiaphragm D dome shaped and S covered by cardiac shadow,. Increase of BV pattern on Lung D/S. Cor site N, CTR 50%. Conclusion : CXR normal
CUE AND CLUE male/ 35 yo Fever 1 week Chilling Headache PE: liverspan 12 cm, traube space dullness(schufn er 2) Lab: plasmodium Vivax, Trombosit: 22.000
PROBLE MLIST
INITIAL DIAGNOSE
PLANING DIAGNOSE
PANING THERAPY
PLANING MONITORING
VS Parasit Count