Doctor on Duty: dr. Indri, dr.

Dea
Co-ass on Duty
: gresia, mita

PATIENT RECAPITULATION

Mr. S, 72 y.o : GERD dd/ myalgia

Mrs. A, 47 y.o : dyspnoe ec overload at CKD o
HD
anemia ec CKD
Mr. M , 23 y.o : DHF grade I
Mrs. S, 58 y.o : dyspnoe ec suspect pleural
effusion sinistra + Ca ovarium susp metastase
Mrs. SA, 57 y.o : obstruction of a. dorsalis
pedis sinistra + ulcus diabetic

PATIENTS IDENTITY
Name
Sex
Date of Birth
Age
Job
Religion
Marital Status
Address

:M
: Male
: 23-8-1993
: 23 years old
: Student
: Moslem
: Single
: Senen

History of Present Illness

Chief complaint : Patient came to the hospital with
chief complaint of fever 3 days before admission.
Patient came with sudden high fever 3 days before
admission. It began on the first day and still has
fever until now. The fever doesnt have a specific
time, and it goes fluctuating every day. He was
recently very well. He went to a General Practicioner
and he had been given some drugs, but the patient
forgot the drugs name and he already did the blood
test (trombocytopenia)

loss of appetite due to nausea and

vomiting were felt since 3 days
ago
Yellowish food containing vomitus
twice per day with volume of 150
cc.

he never experienced these symptoms before

No history of cough, sore throat, stomachaches
No history of gum bleeding spontaneously and when
brushing his teeth and nose bleed.
No history of travelling, flood areas, rat bite.
No history of diarrhea, he had no complaint in urinating
and no complain in defecation.

History of Past Illness

No history of past illness

History of family illness

No family members have similar symptoms

History of Socio-Habits
He neither smokes nor drinks any alcohol

Physical Examination
General State
Consciousness

:
:

Mildly sick
Fully consciousness

Vital Signs
Blood Pressure :
Pulse
Respiratory Rate :
Temperature

120 /70 mmHg

:
84 bpm
20 times/minute
:
38.1 oC

Body Weight
Body Height
BMI

:
60 kg
:
172 cm
20 kg/m2 (NW)

General Examination
Head

: Normocephal

Eye

: anemic conjunctiva (-/-), icteric sclera (-/-)

Ears

: discharge (-)

Nose

: septum deviation (-), discharge (-)

Mouth

: coated tongue (-), hyperemic pharynx (-),

normal T1-T1,

pale mouth mucosa (-), dried

mucosa (-)
Neck

: lymph nodes enlargement (-)

 Thorax: symmetric, intercostals retraction (-)

COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dekstra
Left border : ICS V, linea midclavicularis sinistra
Heart waist: ICS IV, linea parasternal sinistra
Auscultation : regular 1st and 2nd heart sound, murmur
(-), gallop (-)

 PULMO

Inspection : chest within normal shape, symmetries on

static and dynamic state
Palpation

tactile

vocal

fremitus

both

lungs

were

symmetries, chest expansion ssymmetries

Percussion : resonant both lungs
Auskultasi : vesicular breathing sounds, rales (-/-), wheezing
(-/-)

Abdomen

: flat, not distended,

timpani, no enlargement of liver & lien

Extremities : warm, pitting edema (-), cyanosis (-), CRT < 2

seconds, torniquet test (+)

Laboratory Results
9 June 2016

Nilai Rujukan

Hemoglobin

14.7

12-16 mg/dL

Hematokrit

48

37-47%

Eritrosit

5.3

4.3-6.0 juta/uL

Leukosit

5600

4800 10800 /uL

Trombosit

103.000

150000 400000 /uL

MCV

77

60 96 fL

MCH

28

27 32 pg

MCHC

36

32 36 g/dL

Hematologi Rutin

RESUME
Mr. M, 23 years old, came with sudden high fever 3 days
before admission. It begun on the first day and still has
fever until now. The fever doesnt have a specific time, and it
goes fluctuating every day. He had given some drugs, but his
fever still high. Loss of appetite due to nausea and
vomiting were felt since 3 days ago. Yellowish food
containing vomitus twice per day with volume of 150 cc. He

couldnt eat but drink well.

Physical examination showed BP: 120/70
Torniquest test (+)
Laboratory results showed thrombocytopenia

, T: 38.1 C,

Diagnosis
Working diagnosis

DHF grade I
Differential diagnosis:

Thyphoid fever

List of Problem
DHF grade I

Discussion

DHF grade I, Based on: (WHO 1997)

HT and PE:
history of sudden fever 2 7 days, biphasic
One or more than bleeding manifestation:
Tourniquet test (+) > 20 petechiae within 2,54 cm2
Petechiae, ecchymoses, or purpura
Mucosa bleeding, GI bleed or others
Hematemesis or melena

Lab:
Thrombocytopenia ( < 100.000/mm3) 103.000/mm3
One or more plasma leakage signs:
HCT > 20% compare to average HCT in ages, gender and
population 48%
HCT < 20% from baseline HCT after fluid therapy
Evidence of pleural effusion, pericard effusion, ascites and
hypoproteinemia

Dengue fever grading

Grade

I:
Fever with untypical constitutional
symptoms,
bleeding manifestation (+) by
tourniquet test

Grade II: Grade I with spontaneous bleeding

Grade III:

Compensated DSS (characterized by tachy- or

bradycardia or hypotension, with cold skin and
agitated)

Grade IV:Uncompensated DSS (characterized by irregular

blood pressure and heart rate)

Plan and Treatment

Non

Monitoring plans:
Platelet

SGOT/SGPT
Urine output

pharmacological
interventions:
Bed rest
Oral
fluid

max. 2L/day

intake

Pharmacological

interventions:

IVFD RL 1000 cc/2

hours (loading)
Paracetamol
tab.
500 mg, q8hr (Ondemand)
Imboost 3x1

Prognosis
Quo ad Vitam

bonam
Quo ad Functionam
bonam
Quo ad Sanationam
bonam

: dubia ad
: dubia ad
: dubia ad