ALL CASES

EMERGENCY DUTY
HARI / TGL JAGA
NAMA SUPV IGD
NAMA RESIDEN JAGA
 DENTA

All Cases
Emergency Case :
Priority Case :
Non Priority Case :
Other Case :
TOTAL : cases
 EMERGENCY CASE DENTA

Name & Diagnosis Ward

1. Bb Mrs / F / 0 d.o / Magelang NICU
Cc :
dr Sp AK
Ass:

INTERESTING
CASE
 PRIORITY CASE DENTA

Name & Diagnosis Ward

1. MDP / M / 12 y.o / Yogyakarta Estella II
Cc :
dr Sp AK
Ass:
 NON PRIORITY CASE DENTA

Name & Diagnosis Ward

1. RNH / F / 1 y.o / Yogyakarta Amb
Cc :

Ass:

2. HH / F / 5 y.o / Yogyakarta
Cc : Amb

Ass:
 OTHER CASE DENTA
Name & Diagnosis Ward
1. MA / M / 16 y.o / Yogyakarta Plastic Surgery
Cc :

Ass:

2. AF / F / 3 m.o / Wates
Cc : Neuro Surgery

Ass:
THANK YOU
SR, bb Mrs / F / 0 d.o / Magelang
Assessment
Subjective

Plan:
Objective
Chest and Abd X Ray
 DENTA
Blood Examination SR, bb Mrs
Parameters Units Normal Value
Erythrocyte x106/mm3 4.1-6.1
Hemoglobin g/dL 16.5-21.5
Hematocryte % 48-68
Leukocytes /mm3 9.000-37.000
Platelet /mm3 150.000-
450.000
Neutrophils % 22-46
Lymphocytes % 37-73
MCV fL 76-92
MCH pg 23-31
MCHC g/dL 32-36
 DENTA

Parameters Units Normal Value

Na Mmol/L 136-145
K Mmol/L 3.5-5.1
Cl Mmol/L 98-107
Ca Mmol/L 2.1-2.5
Bloog Glucose Mg/dl 80-140
Alb gr/dl 3.97-4.94
CRP Mg/L <5
IT ratio
IM ratio
 Blood Gas Analyze
Result Normal range
pH 7.35-7.45
PCO2 35-45
HCO3 22-26
PO2 80-95
BE
Laktat 0.36-1.25

Result:
Data list
MA / M / 2 y.o / Yogyakarta

Subjective : Objective :
 PAT Initial Assesment :
CNS dysfunction

Initial Management :
TICLS ↓ WOB N
A : positioning
B : O2 NK 1 lpm
C : IVFD Tridex 36cc/h
Pale (-), Cyanosis (-)
Ass:
Plan
 DENTA
Blood Examination M Akmal
Parameters Units Normal Value
Erythrocyte x106/mm3 3.4-5.2
Hemoglobin g/dL 9.6-15.6
Hematocryte % 34-48
Leukocytes /mm3 5.5-17.5
Platelet /mm3 150.000-
450.000
Neutrophils % 22-46
Lymphocytes % 37-73
MCV fL 76-92
MCH pg 23-31
MCHC g/dL 32-36
 DENTA

Parameters Units Normal Value

Na Mmol/L 136-145
K Mmol/L 3.5-5.1
Cl Mmol/L 98-107
Ca Mmol/L 2.1-2.5
Blood Glucose Mg/dl 80-140
Procalsitonin Ng/ml <0.50
BUN Mg/dl 6-20
Cr Mg/dl 0.7-1.2
Alb g/dl 3.97-4.94
SGOT U/L <40
SGPT U/L <41
 Parameters Units Normal Value DENTA

Na Mmol/L 136-145
K Mmol/L 3.5-5.1
Cl Mmol/L 98-107
Ca Mmol/L 2.1-2.5
Blood Glucose Mg/dl 80-140
Procalsitonin Ng/ml <0.50
BUN Mg/dl 6-20
Cr Mg/dl 0.7-1.2
PPT S 12.3-15.3
APTT S 27.9-37
INR 0.9-1.1
Alb Gr/dl 3.4-5
 Blood Gas Analyze
Result Normal range
pH 7.35-7.45
PCO2 35-45
HCO3 22-26
PO2 80-95
BE
 LCS Analyze
Result Normal
Protein 0.02-0.05
None LCS Negative
Pandy LCS Negative
Cell 0-10
PMN 0-6
MN 0-6
Glucose 50-80
Erythrocyte 0
LDH 0
 LABORATORIUM
Dengue Monitor ZA / f / 6y.o/16kg

IV Tgl: 03-08-17 V Tgl: 04-08-17

R N PP Hct
1 3 5 7 9 11 13 15 17 19 21 23 1 3 5 7 9 11 13 15 17 19 23 21 1
2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24 2
72

64 200
56 180 RF 10 cc/kg
RL 3 cc/kg/hr RF 10cc/kg
RF Holiday Segar
48 55 cc/h
160 RF 20cc/kg
40 55
140
135
32 51 130
120
42%
24 47
100
100
43
80

60 6.5 39 70

40 5.5 35

4.5 31 4.4

3.5 27 27,3% 4
2.5 23 18,6%
Platelet (/mm3) 83.000 7.000 75.000
Abdominal circ. (cm) 48cm 50cm

Hematocryte Blood pressure Ringer Laktat

Plasma protein Pulse rate
 NEUROLOGICAL EXAMINATION
Meningeal sign: Neck stiffnes (-) Kernig’s sign (-) Brudzinski (-)
Leg Arm
Right Left Right Left
Movement limited limited limited limited
Strenght sdn sdn sdn sdn
Trophy Eutrophic Eutrophic Eutrophic Eutrophic
Tonus (+)↑ (+)↑ (+)↑ (+)↑
Physiological reflex (+)↑ (+)↑ (+)↑ (+)↑
Pathological reflex positive positive Negative Negative
Sensibilitas Normal Normal Normal Normal
Clonus positive positive
 Urine Examination KQJ
Reference Range
Color
Urine gravity 1.005 – 1.030
Protein Negative
Bilirubine Negative
Urobilinogen
pH 4.5 - 8
Keton Negative
Glucose Negative
Blood Negative
Nitrit Negative
LE Negative
Erithrocyte