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Family history
No one in the family has history of allergic disease
Social history
In the house there was a bee hive
Physical examination
Appearance : moderate ill
GCS : E4V5M6
Blood pressure : 90/60 mmHg
Temperatur axilla : 37.0 OC
Pulse rate : 120 x/min, regular
Respiratory rate : 24 X/min
GENERAL STATUS
Eyes : Ane -/-, ict -/-, pupil reflex +/+ isochoric,
palpebral oedema +/+
ENT : Tonsil T1/T1; pharing hiperemis (-)
Neck : JVP 0 cm H2O
Chest Examination
Heart
Inspection : Ictus cordis: not seen
Palpation : Ictus cordis :palpable at MCL S ICS V
Percussion : Upper border : ICS II
Right border : Right PSL
Left border : Left MCL
Auscultation : S1 S2 single regular, murmur (-)
Physical examination
Lung
Inspection : symetric , active and passive
Palpation : vocal fremitus : normal
Percussion : sonor / sonor
Auscultation : Ves +/+ , Rh -/- , wh -/-
Abdomen
Inspection : distention (-), redness, urticaria
Auscultation : normal bowel sounds
Palpation : liver : unpalpable
spleen : unpalpable
tenderness (+) epigastric region
Percussion : tymphani
Extremities
Cold + / +, Edema - / -
Laboratory examination (25/4/2016) Complete Blood Count
Parameter
Parameter Unit
UnitValue
Value Normal
NormalValue
Value Results
Results Remark
Remark
WBC 103
WBC 103/L
/L 4.10-11,00
4.10-11,00 8,83
22.10 Normal
High
LYM 103
LYM 103/L
/L 1,00-4,00
1,00-4,00 1,12
4.50 Normal
high
NE 103
NE 103/L
/L 2,5-7,5
2,5-7,5 1,3
16.30 Normal
High
RBC 106
RBC 106/L
/L 4,50-5,90
4,50-5,90 6,43
6.12 Normal
High
HGB
HGB g/dL
g/dL 13,5-17,5
13,5-17,5 13,89
18.10 Normal
High
HCT
HCT %
% 41,0-53,0
41,0-53,0 44,64
51.80 Normal
Normal
MCV
MCV fL
fL 80,0-100,0
80,0-100,0 90,55
84.60 Normal
Normal
MCH
MCH Pg
Pg 26,0-34,0
26,0-34,0 28,16
29.50 Normal
Normal
MCHC
MCHC g/dL
g/dL 31,0-36,0
31,0-36,0 31,11
31,11 Normal
Normal
RDW
RDW %
% 11,6-14,8
11,6-14,8 12
13.20 Normal
Normal
PLT 103
PLT 103L
L 150-440
150-440 180,10
269.00 Normal
Normal
MPV
MPV fL
fL 6,80-10,0
6,80-10,0 7,10
7,10 Normal
Normal
Laboratory examination (25/4/2016) Clinical Chem
Monitoring
Vital sign
Complaint
Thank You