Duty Report

20-21st January 2016

Adviser : dr. Bina Akura, SpA
Madinatul Munawwaroh - 1111103000055

Recapitulation
New patients : 2 patients
Stagnant patients : 4 patients

New Patients
Name

Age

Sex

Diagnosis

An. MI

11 yo

Dengue fever

By. Ny I

3 day

LBBW with low intake

Stagnant Patients
Name

Age

Sex

Diagnosis

An. FI

1 yo

Observation of
seizure ec epilepsy

By BP

9 mo

Suspected meningitis

An. M

3 yo

Anemia gravis

An. AS

8 yo

Suspected
appendicitis

Identity
Name
Age
Sex
Adress
No MR
Admission

: An. MI
: 11 yo
: Male
: Jl. Rambutan
: 01407516
date : 20 January 2016, 20.00 WIB

Parents identity
Mother: Mrs.W, 35 yo, housewife
Father: Mr.Y, 38 yo, employee

Chief complaint
Fever since 3 days before admission

Recent history of
illness
3 days before
admission
Fever suddenly high,
happened all day, only
decrease with
antipiretic
There is headcahe,
retroorbital pain,
muscle and joint pain
There is no red spots
on skin, gum bleeding,
or nosebleed
Thereisisnausea
no cough,
There
and
cold,
painfull
vomitting especially
swallowing,
after eating.difficult
There isto
breath,
or pain
during
epigastric
pain
urination

2 days before
admission

1 days before
admission

Fever remain high,

there is no seizure

Fever remain high, no

red spots on skin

The patient was taken

to the doctor, given
the antipiretic

Still there is headache,

retroorbital pain,
muscle and joint pain

No relieving of
symptoms

Still there is epigastric

pain , nausea and
vomitting
Appetite decrease
No complains of
urination and
defecation

Previous history of illness

Patient never had the same history like this

before
Never been hospitalized

Family history
Patients brother has just recovered from

similar complaints 2 months ago

Social & environment

There are some people arround patients

house who suffered from similar complaints

History of pregnancy, delivery and

immunization
History of pregnancy
During pregnancy mother control to midwife routinely, no
cosumption of drugs, and no history of illness during
pregnancy
History of delivery
Patient is the 2nd child, born aterm, spontaneously, assisted
by midwife, BBW 3000 grams, BBL 50 cm, no cyanosis, no
icteric, cry spontaneously
History of immunization
The mother said the immunization was completed until 9 mo
but she forgot the details

History of growth &

development
Now in 1st grade of junior high school
Never a left grade
Has many friends and good socialization

Physical examination
General physics
: looks moderately sick
Conciousness
: Compos mentis
Vital sign
Blood pressure
: 110/65 mmHg
Heart rate
: 105 x/min, regular
Respiratory rate
: 24 x/min
Temperature
: 38,3 oC (axilla)
Nutritional status
BW

W/A
: 32 kg
BW/A = 88,8
%= 88 %
H/A = 97 %
BH
: 140 cm
W/H = 96 %
Nutrisional status : Normal

Physical examination
Head : normocephal
Eyes : conjungtiva anemic-/-, icterus of

sclera -/Nose : deformity (-), bleeding (-), secret

(-)
Mouth : gum bleeding (-), mucous edema
(-), pharing is not hypermic, tonsil T1/T1
Ears : normotia, minimum cerumen
Neck : lymph node not palpable

Physical examination
Cor:
I
P

: iktus cordis not visible

: iktus cordis palpable in ICS V linea
midclavicula sinistra
P :
Right

: ICS IV linea parasternalis dekstra

Left
: ICS V medial from linea midclavicula sinistra
Waist : ICS II linea parasternalis sinistra

A : S I-II regular, murmur (-), gallop (-)

Physical examination
Pulmo

I : chest movement was symmetries when static and

dynamic
P : Chest expansion was symmetries
P : Sonor in both of pulmonary
A : Vesiculer +/+, ronkhi -/-, wheezing -/- stridor (-)
Abdomen : not distended, Bowel sound (+) normal,
epigastric pain (+), hepar and lien not palpable,
turgor return normally
Extremity : Warm acral, CRT < 2 second, cyanosis (-)
Skin : petechie (-)
Rumple lead (+)

Lab Examination (20/01/2016)

Examination

Result

Refrence Number

Hemoglobin

13,3

10,8-15,6 g/dl

Hematokrit

39

33-45 %

Leukocyte

3,4

5,0-14,5 thousand/ul

Trombocyte

103

181-521 thousand/uL

Eryhtocye

5,06

4,40-5,90 jt/ul

MCV

76,3

80,0-100,0 fl

MCH

26,4

26,0-34,0 pg

MCHC

34,6

32,0-36,0 g/dl

RDW

13,3

11,5-14,5 %

HEMATOLOGIC

MCV/MCH/MCHC

Diagnosis
Dengue fever
DD/DHF grade I

Therapy and further

examination
IVFD RL 1500 + (20x12) = 1740 cc/24 hours

24 tpm macro
Parasetamol (10-15mg/kgbb/kali) : 4 x 500 mg po
Ranitidin 2 x 50 mg IV
Diet 1920 kkal/day
Bed rest
Monitor vital sign every 6-12 hours
Check DPL every 12 hours
Check dengue blot
RLD

PROGNOSIS
Ad Vitam
: Bonam
Ad Sanationam : Bonam
Ad Fungsionam : Bonam

Thank you