MORNING REPORT

6th November, 2013

PATIENT IDENTITY

Name Sex Age Nationality Ethnic Occupation Marital Status Religion Address Dua ToA

: YUL : Female : 20 years old : Indonesia : Jawanese : Student : Unmarried : Islam : Jl Permata GG Bidadari, Nusa : 13.06 WITA

Anamnesis
Chief complain : Fever Patient came with chief complaint of high fever since 3 days BATH. The fever was said to be continuously high and only reduced after consuming paracetamol but the fever always reappeared again after few hours. Patient also complained headache since 3 days BATH. The headache felt like pressure was applied on the patients head and was felt the whole day and got worsened during physical activity.

Anamnesis

Patient also felt nauseous and could not consume much food but was said to be able to drink plain water. The patient complained of vomiting since 3 days ago the content being water and any food that she had consumed. The patient vomited in average 4 to 5 times a day and each time a estimated volume between a quarter to half an aqua glass. Patient also complained of having muscle and joint pain specifically in her knees. Which was persistent. Bleeding from the gums, petechia or epixtasis was denied. Normal consistency and coloration of stool and urination with normal frequency.

ANAMNESIS CONT
Past illness history History of asthma, hypertension, DM, and heart disease was denied by the patient.

Family history There has been no such complaints from family members.

Social history A fellow collage mate was said to have suffered from dengue fever a week ago. Smoking (-), alcohol (-)

Medication history Paracetamol 3 x 500 mg for 3 days.

Physical Examination
Appearance Level of conciousness Blood pressure Temperatur axilla Pulse rate Respiratory rate Weight Height : Moderately ill : E4V5M6 : 120/80 mmHg : 38 OC : 80 x/min, reguler : 20 x/min : 50 kg : 165 cm

BMI

: 18.37kg/m2

Physical examination
Status General Eyes : Anemia -/-, ict -/- PR +/+ Isokor ENT : WNL Neck : Lymph node enlargement (-) JVP PR 0 cm H2O Chest examination HEART Insp : ictus cordis not visible Palp : ictus cordis not palpable Perc : UB: ICS II, RB: PSL D, LB: MCL S Ausc : S1S2 single regular murmur (-) LUNG Insp Palp Perc Ausc : symmetrical : vocal fremitus N/N : sonor/sonor : Vesicular +/+; ronchi -/-; wheezing -/-

Abdomen
inspection auscultation palpation : liver : spleen percussion : distention (-) : normal bowel sounds : unpalpable : unpalpable : tymphani

Extremities
warm + + edema + + tourniquet Test (+) - - -

Complete Blood Count (4th November 2013)

Parameter WBC -Ly -Mxd -Neut RBC HGB HCT MCV MCH MCHC RDW PLT Result 2,5 Unit 103/L Remarks L Reference range

4,1-11,0 1,0-4,0 0,1 1,2 0 ,0 0,5 4,0 5,2 12,0 16,0 36,0 46,0 80,0 100,0 27,0 31,2
31,0 36,0 11,0 14,8 150 440

Abdomen: Insp : distensi (-) 3/ L 0.6 24.4% 10 3/ L Ausc sound (+) normal 0.6 23.5 % : Bowel 10 Palp : H/L not palpable 1.3 52.1% 103/ L tenderness(-) 4.35 106/L Ballotment (-) 12.6 Perc: Tympani g/dL (+)
36.1 % fL Pg g/dL % 103/L L

- edema Extremity: pitting

29.0 35.2 11.9 81.0

82.3

+, warm + + +

ASSESSMENT
Susp. DHF gr. I (day 3)

TREATMENT
Hospitalized IVFD RL 30drips/min Paracetamol 3 x 500 mg Drink water 1,5-2 liters daily

PLANNING
Planning Diagnosis:
Serologi DHF day VII

Monitoring
VS Complaints CBC @ 12 hours