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dr.Herman - IPD
History of past illness: History of medication: she was admitted in PHC for 3 Days
and got medication. But epigastric pain didnt relived yet.
Social history: She is a student. There is no neighbour or
family who had been diagnosed Dengue infection.
Family history: No family has Dengue infections or any fever
recently. DM (-), HT (-) in family.
PHYSICAL EXAMINATION
BP : 100/60
mmHg
PR : 99 bpm
RR : 18 tpm
Tax : 36.3 C
GCS 456
Thorax : Cor
Pulmo
Abdomen
Extremities
Lab
Value
Leukocyte
6970
(Normal)
Lab
Value
4.70011.300/L
RBS
108
70-100 mg/dl
Haemoglobine 16,80
MCV
79,5
MCH
29,5
11,4-15,1 g/dl
80-93
27-31
Ureum
32,1
20-40 mg/dL
Eritrocyte
5,7
4.0-5.5 x
103L
Creatinine
0,67
<1,2 mg/dL
PCV
45,3
38-42%
Trombocyte
30.000
142.000424.000/L
Na
130
136 145
mmol/L
5,3
3,5 5 mmol/L
Cl
104
98 106 mmol/L
Anti
dengue
Ig M
Ig G
SGOT
380
0-32 mU/dl
SGPT
186
0-33 mU/dl
0/0/73,0/18
,0/11,0
Diff Count
(Normal)
URINALYSIS
(dipstick)
Result
Result
SG
1.025
10 x
PH
6.0
Epithelia
4,0
Leucocyte
Cylinder
7,22
Nitrite
Hyaline
Protein
trace
Granular
Glucose
Leukocyte
Erythrocyte
Erythrocyte
40 x
Keton urine
trace
Eritrosit
2,3
Urobilinogen
Leukocyte
3,6
Bilirubin
Crystal
Bacteria
32,4
coccus/stab
ECG
CXR
AP position, asymmetric, KV enough, less
inspiration
Soft tissue thick, Bone normal
Trachea in the middle
Hemidiaphragm domeshaped, S covered by
radioopaque imaging
Phrenicocostalis angle D/S sharp
Pulmo D/S: BVP D/S increased
Cor: site N, size 58% in AP position, shape N
Conclusion: normal CXR
Thank You