CUE AND CLUE

Female/35 yo
AMS

PL

1. Altered
mental state

Idx

1.1 hepatic
encephalopa
thy dt acute
liver failure

Fever for 4 days

Abruptly onset
Nausea
Vomiting
Epigastric pain
Menstruation
PE
GCS 446 agitated
BP 107/70 mmHg
PR 98 bpm
RR 20 tpm
NCT 75 second
Lab
SGOT/SGPT
8750/2060 U/L
Prolonged FH
Thrombocyte

1.2
hyponatremi
a
hypoosmolar
hypovolemia

PDx

Blood
amonia

PTx

Oxygen 2-4 lpm NC

soft diet 1700
ccal/day
Infuse comafusin
2x500cc
Infuse NaCl 0.9%
10cc/kgBW/hr in ER
--. Infue assering 1
liter 30 dpm

PMo

GCS

PEd

Condition
and
prognosed

CUE AND CLUE

Female/35 yo

PL

2. Acute
liver failure

Idx

PDx

2.1 DHF
infection

Anti HAV,
HBsAg,
antiHCV

AMS
Nausea

2.2 acute
fulminant
hepatitis

Vomiting
Epigastric pain
menstruation
PE
GCS 446 agitated
BP 107/70 mmHg

2.3
leptospirosis

Darkfield
microscope
examination
for leptospira
Leptotex

PTx

Avoid hepatotoxic
drug
Treat underlying
disease
Plan for give SNMC

PMo

PEd

SGOT/SGPT,
ureum/creati
nin every 3
days

Condition and
prognosed

PR 98 bpm
RR 20 tpm
Number connecting
teset
Lab
SGOT/SGPT
8750/2060 U/L
Prolonged FH
Thrombocyte 38.000
11.000
Albumine 2.92 g/dL
IgG and IgM
antidengue +/+
Ur/Cr 61.80/1.76
mg/dL

PL

Idx

PDx

PTx

PMo

PEd

CUE AND CLUE

Female/35 yo

3. DHF with
DSS (?)

PCR

AMS

D-dimer

Fever for 4 days

Fibrinogen

Abruptly onset
High grade fever
Nausea
Vomiting

Oxygen 2-4 lpm

NC soft diet 1700
ccal/day
Infuse NaCl 0.9%
10cc/kgBW/hr in
ER --. Infuse
assering 1 liter
30 dpm
Transfusion FFP 10
cc/KgBW/day
Transfusion TC 4

GCS
Bleeding
tendencies
CBC/12
hours

Condition and
prognosed

Epigastric pain
menstruation
PE
GCS 446 agitated
BP 90/50 at ER
107/70 mmHg
PR 98 bpm
RR 20 tpm
Lab
SGOT/SGPT
8750/2060 U/L
Prolonged FH
Thrombocyte 38.000
11.000
Albumine 2.92 g/dL
IgG/IgM antidengue

packs/day

+/+

CUE AND CLUE

Female/35 yo
AMS
Nausea

PL

4. Renal
azotemia

Idx

PDx

PTx

PMo

4.1 dt no 3

Equal fluid balanced

4.2
hepatorenal
syndrome

Avoid nephrotoxic
drug

ureum/creati
nin every 3
days

PEd

Condition and
prognosed

Vomiting

Ur/Cr 61.80/1.76
mg/dL
BUN/Cr 16.40

CUE AND CLUE

Female/35 yo
Nausea
Vomiting
Epigastric pain
no history of DM
Trias DM (-)
RBS 336 182 mg/dL

PL

5.
Hyperglycemia

Idx

PDx

5.1 reactive

HbA1C

5.2 DM type 2

TTGO

PTx

Confirmed
diagnosed

PMo

PEd

FPG/2hPP
BG

Condition and
prognosed

CUE AND CLUE

Female/35 yo
AMS
Fever for 4 days
Abruptly onset
Nausea
Vomiting
Epigastric pain

PE

PL

6.
Hyponatremia
hypoosmolar
hypovolemia

Idx

6.1 volume
depletion

PDx

PTx

Infuse NaCl 0.9%

10cc/kgBW/hr
infusion assering 1
liter assering 30
dpm

PMo

SE level
GCS

PEd

Condition and
prognosed

GCS 456 agitated

Na 124 mmol/L
Osm 266
mOSm/kgBW

Summary of database
Mrs Anisa/35 years old/ward 26/bed
1

Physical Examination
General appearance: looked severely ill
GCS : 446

Labarotory findings
Leukosit : 7710
Haemoglobin : 14.20

history taking heteroanamnesa from

her husband
Chief complaint : fever
patient suffered from fever since 4
days before admission, abruptly onset
high grade fever
accompanied with
nausea and vomiting about 3x/day
contain of residual food and fluid
without blood.
She also complain about epigastric
pain
since
3
days
ago
and
arthralmyalgia all over her body. No
history of gum bleeding, epistaxis,
bloody stool nor ptechiae in her body.
She is on her menstrual period now, but
no sign of prolongation or more than
usual (day 3)
She go to healt clinic near her home,
got 1 kind of drug didnt know the name,
because
she
didnt
feels
any
improvement she go to RSSA.
Her
husband tell that when he come to ER,
she begin to not communicate well she
got menstrual cycle that the volume is
morethan usual
She
didnt
have
history
of
hypertension nor diabetes mellitus. No
history of decreased of body weight,
frequent urination, frequent hungry,

BP :107/70mmHG
HR: 98
RR:20
Tax: 36
Head : Anemic Iceteric

Neck : JVP R+ 0 cm H2O (0)

Thorax :
C/ Ictus invisible, palpable at Mid
Clavicular line
Sinistra ICS V
Right heart margin sternal line dextra
Left heart margin ictus
S1 S2 single, murmur (-)
L/ Simetriis, s/s v/v rh-/- wheezing -/v//v
-/-/v/v
-/-/Abdomen : Flat, Soefl, Bowel sound (+)
Normal, liver span 16 cm, palpable at 4
cm below arcus costae. traube space
tympani shifting dullness (-).
Extremities : Edema -/- , warm acral +/
+,

MCV : 78.00
MCH :27.60
PCV : 40,10%
Thrombocyte: 11,000
Eosinofil : 0.0
Basofil : 4.4
Neutrofil : 53.9
Lymphocyte : 32.6
Monocyte : 9.1
Ureum : 61.80
Creatinine : 1.76
Natrium : 124
Kalium : 4.43
Chloride : 498
RBS : 336 182
SGOT : 8750
SBPT : 2060
Albumin : 2.92
PPT : 12.30
APTT : 33.90
IgG anti dengue (+)
IgM anti dengue (+)
BGA :
pH : 7.38
pCO2 : 21.2
pO2 : 87.3
HCO3- : 12.6
BE : -12.7
02 saturation : 96.2%

frequent eating.
She rarely checked her blood
pressure, so didnt noticed her blood
pressure before
She didnt have history of drinking
traditional potion nor over the counter
drug
She is food seller, had 2 children

UOP : 200cc/hour

conclusion : Acidosis metabolic fully

compensated with alkalosis respiratoric
Urinalysis :
Protein : 2+
glucose : 2+
erithrocyte : 3+
keton urine : 1+
40x :
leukocyte : 4.8 hpf
ECG :
Conclusion : normal sinus rhytm with
Heart rate 91 beats/minute
Chest Xray :
Conclusion: normal chest X Ray