*

SUPERVISOR : dr. Nelly Rosdiana , M.Ked (PED) SP.A (K)

PRESENTED BY : Karthika Rajasegaran (120100469)

*
*Dengue virus infection is a disease transmitted through
mosquito which is Ae. Aegipty and Ae. Albopictus.
*Dengue virus infection is a global problem that is mainly
found in tropical and subtropical regions.
*Patients who are infected will have symptoms of mild to high
fever, accompanied by headache, pre orbital pain, muscles
and joints, until spontaneous bleeding.
*Total DHF case reported last year in 34 province of Indonesia
was 71,668 people and 641 of them died. The total number of
cases reported was less compared to the year 2014 with the
total number of cases reported was 112,511 and 871 of them
died.
 *
* Dengue haemorrhagic fever (DHF):

A syndrome due to the dengue virus that tends to affect

children under 10, causing abdominal pain, haemorrhage
(bleeding) and circulatory collapse (shock).
There is bleeding with easy bruising, blood spots in the skin
(petechiae), spitting up blood (hematemesis), blood in the
stool (melena), bleeding gums and nosebleeds (epistaxis).
 *
*The term haemorrhagic fever in Southeast Asia
was first used in the Philippines in 1953.
*InIndonesia, the disease was first reported in
1968 in Surabaya with the number of people 58
people with the death of 24 people (41.3%)
*Total DHF case reported last year in 34 province
of Indonesia was 71,668 people and 641 of
them died. The total number of cases reported
was less compared to the year 2014 with the
total number of cases reported was 112,511 and
871 of them died.
*
Bite of a virus
carrying aedes
mosquito
Injects fluid to victims
skin and virus enters
blood stream
Infects cell and
generate cellular
response

Stimulates release of
cytokines & cytokines
destroys cell membrane and
cell wall

Dengue infection
*
* A sudden high fever for 2-7 days with temperature of (38-40C)
* Tourniquet test +, found (purpura) bleeding
* The presence of bleeding in the eyelids (conjunctiva), nosebleed.
* Faeces with wastes mixed with blood (melena), and others.
* Liver enlargement (hepatomegaly)
* Blood pressure decreases, causing shock.
* Trombositopenia & increase in hematocrit values at 20% normal value
* nausea
* Vomiting,diarre & decreased appetite (anorexia)
* Abdominal pain / Epigastrium pain
* Headache
* Nose bleed and gums.
* Fever causes soreness / pain in the joints.
* The emergence of red spots on the skin due to rupture of blood vessels.
 *
* Diagnosis of DHF is made when there are 2 clinical criteria and 2 laboratory
criteria.

Clinical criteria:
* 1. Sudden Acute Fever 2-7 days
* 2. There haemorrhagic manifestations characterized by:
- Rumple lead test (+)
- Petechiae, ecchymosis, purpura
- Mucosal bleeding, epistaxis, bleeding gums
- Hematemesis and melena

Laboratory criteria:
* Thrombocytopenia (100,000 / mm3 or less)
* There is at least one sign of plasma leakage as follows:
- Increased hematocrit> 20% compared to standard according to age and gender.
- Decrease hemtokrit> 20% after receiving fluid therapy, compared with the previous
hematocrit values.
- Signs of plasma leakage such as pleural effusion, ascites or hipoproteinemia.
*
*
*Monitor Vital Signs Frequently
*Supportif therapy : Fluid Management
Fluid type: Cristaloid Solution
*Paracetamol is given when patient is
having fever.
*Transfusion of blood given when there is
an indication of it.
*
*typhoid fever
*Measles
*Influenza
*Chikungunya
*Leptospirosis
*Idiopathic thrombocytopenia
purpura (ITP)
 *
PI, a 17 years old boy, with 50 kg of body weight and 160 cm of
body height, came to RSUP Haji Adam Malik on 9 Mei 2016.His
main complaint was fever.

*History of disease:
It has been experienced by patient for the past 5 days before being
admitted to the RSUP Haji Adam Malik hospital. Spontaneous
bleeding was found. There was bleeding in his gums for the past 5
day. Body rash was found around the patients body. He also had 5
days history of malaise and generalised epigastric pain. He also
complained of having Blackish colour faeces. There was no cough
and sore throat. Patient complained of having headache and
vomiting. Patients parent also told that many Dengue cases reported
around their housing area lately.
Patient was referred to Adam Malik Hospital from a clinic.
* History of medication :-IVFD Ringer Laktat
- Inj.Ranitidin
- Inj Metoclopramide
- Paracetamol
* History of family : None
* History of parents medication : None
* History of pregnancy :The age of the patients mother
was 24 during pregnancy. The
gestation age was 9 months.

* History of birth : The patient was born with normal delivery

and cried immediately after birth. Body
weight at birth was 3000 gram, body length
at birth was unclear and head circumference
was unclear. Cyanosis (-), Jaundice (-).
* History of feeding : Exclusive breast feeding was
given for about 6 months,
formula feeding , porridge
milk (8-11months), porridge
rice (8months-1 years),
family food (2-3 years old).

* History of immunization : Not clear.

Patients mom doesnt
have good knowledge about
immunization.
* History of growth & development : Growth is normal.
The patient had developed
talking, crawling, and
walking skills on time.
Physical Examination:
Present status:
Sensorium : Compos Mentis Body temperature: 38.9C
HR: 78 bpm RR: 30times/min
BW: 50 kg BH: 160 cm
BP : 110/70
anemic (-), icteric (-), dyspnoea (-), cyanosis (-), edema (-).

Localized status:
Head : Normal
Face : edema (-)
Eye : light reflex (+/+), isochoric pupil, pale palpebral
conjunctiva(-/-)
Ears : both ear lobes are normal morphologically
Nose : septum deviation (-), nasal canule (-)
Mouth : dysphagia (-)
Neck : Lymph node enlargement (-),
Thorax: Symmetrical fusiform, retraction (-)
HR: 78 bpm, regular, murmur (-/-)
RR: 30 x/i, regular, ronchi (-/-)
Abdomen :Soepel, normal peristaltic, liver and spleen
unpalpable
Extremities : pulse 78 bpm, regular, adequate p/v, felt
warm, CRT < 3, pitting edema (-),Rumple lead test (+)
Genital : Male
Differential diagnosis : 1. Dengue Hemorrhagic Fever
2. Dengue Fever
Working diagnosis : Dengue Haemorrhagic Fever without
Shock
Medications : IVFD Ringer Laktat 5cc/kgbw/hr
Paracetamol 3 x 500mg
Ranitidin inj/8hour/iv
Monitor vital sign
Complete blood test
 *
Test Result Unit References

Hemoglobin 15.9 g% 13-18

Erythrocyte 5.61 106/mm3 4.50- 6.50
Leucocyte 3,210 103/mm3 4000-11000
Thrombocyte 66,000 103/mm3 150000-450000
Hematocrite 44 % 39-54
Eosinophil 1,20 % 1.00-3.00
Basophil 1.10 % 0-1
Neutrophil 19,40 % 50.00-70.00
Lymphocyte 53.00 % 20.00-40.00
Monocyte 6,10 % 2.00-8.00
Neutrophil absolute 3.2 103/L 2.7-6.5

Lymphocyte absolute 2.5 103/L 1.5-3.7

Monocyte absolute 0.35 103/L 0.2-0.4

Eosinophil absolute 0.07 103/L 0-0.10

Basophil absolute 0.06 103/L 0-0.1

MCV 82 Fl 81-99
 *
Test Result Unit References
Hemoglobin 12.6 g% 13-18
Erythrocyte 4.42 106/mm3 4.50- 6.50
Leucocyte 3.570 103/mm3 4000-11000
Thrombocyte 69,500 103/mm3 150000-450000
Hematocrite 44 % 39-54
Eosinophil 0.95 % 1.00-3.00
Basophil 0.50 % 0-1
Neutrophil 30.20 % 50.00-70.00
Lymphocyte 55,20 % 20.00-40.00
Monocyte 7.80 % 2.00-8.00
Neutrophil absolute 2.8 103/L 2.7-6.5
Lymphocyte absolute 2.92 103/L 1.5-3.7

Monocyte absolute 0.32 103/L 0.2-0.4

Eosinophil absolute 0.04 103/L 0-0.10
Basophil absolute 0.02 103/L 0-0.1
MCV 80 Fl 81-99
MCH 28,5 Pg 27.0-31.0
Test Result Unit References

Ati DHF IgM Negatif - Negatif

Anti DHF IgG Positif - Positif

Carbohydrate Metabolism

Blood Glucose 93 mg/dL < 200

Liver Function Test

Bilirubin Total 1.20 mg/dL 0.2-1.2

Bilirubin Direct 0.40 mg/dL < 0.5

AST/SGOT 33 U/L 5-34

ALT/SGPT 51 U/L 0-51

 *
Test Result Unit References
Hemoglobin 14.6 g% 13-18
Erythrocyte 5.33 106/mm3 4.50- 6.50
Leucocyte 5,140 103/mm3 4000-11000
Thrombocyte 88,000 103/mm3 150000-450000
Hematocrite 45 % 39-54
Eosinophil 4,70 % 1.00-3.00
Basophil 0,50 % 0-1
Neutrophil 25,30 % 50.00-70.00
Lymphocyte 28,30 % 20.00-40.00
Monocyte 5,68 % 2.00-8.00
Neutrophil absolute 2,30 103/L 2.7-6.5

Lymphocyte absolute 3,28 103/L 1.5-3.7

Monocyte absolute 0.29 103/L 0.2-0.4

Eosinophil absolute 0.24 103/L 0-0.10

Basophil absolute 0.03 103/L 0-0.1

MCV 81 Fl 81-99
MCH 27,4 Pg 27.0-31.0
 *
Test Result Unit References
Hemoglobin 14,2 g% 13-18
Erythrocyte 5.28 106/mm3 4.50- 6.50
Leucocyte 5,410 103/mm3 4000-11000
Thrombocyte 139,400 103/mm3 150000-450000
Hematocrite 45 % 39-54
Eosinophil 10,50 % 1.00-3.00
Basophil 0,50 % 0-1
Neutrophil 24,10 % 50.00-70.00
Lymphocyte 33,70 % 20.00-40.00
Monocyte 10,90 % 2.00-8.00
Neutrophil absolute 2,28 103/L 2.7-6.5

Lymphocyte absolute 2,85 103/L 1.5-3.7

Monocyte absolute 0.58 103/L 0.2-0.4

Eosinophil absolute 0.56 103/L 0-0.10

Basophil absolute 0.04 103/L 0-0.1

MCV 82 Fl 81-99
*
 9th May 2016 (1st day in RSUP HAM)
S Fever (+), Cough (-),Epigastrium Pain(+), Vomiting (+),Gums bleeding
(+),Body rash (+) Blackish feases (+)
O Sens: CM ,Temperature: 39.0o C BW: 50KG
Head :
Eye : light reflex (+/+); isochoric pupil (-/-), pale conjungtiva
palpebra (-/-)
Ear: within normal range
Nose : within normal range
Mouth: gums bleeding (+)
Neck: limph node enlargement (-)
Thorax : symmetric fusiform, refraction (-)
HR: 88bpm, reguler, murmur(-)
RR: 20 bpm, reguler, ronchi (-)
Abdomen: soepel, peristaltic (+) normal, ; liver/ spleen
not palpable
Extremities: pulse: 88 bpm, regular, adequate p/v, warm, CRT < 3,
BP : 110/70 mmHg, Rumple lead test (+)
A Dengue Hemorragic Fever without Shock

P Bed Rest
IVFD Ringer Laktat 5cc/kgbw/hr
Paracetamol 3 x 500mg
Ranitidin inj / 8 hours/iv
Close Monitoring of Vital Sign
Complete blood test
 10th May 2016 (2nd day in RSUP HAM)
S Fever (+) , Cough (-),Epigastrium (-),Vomitting (-),Gums bleeding (-), Body Rash (-),
Blackish feases (-)
O Sens:CM ,Temperature: 38.5C BW: 50KG
Head :
Eye : light reflex (+/+); isochoric pupil (-/-), pale conjungtiva palpebra (-/-)
Ear: within normal range
Nose : within normal range
Mouth: gums bleeding (-)
Neck: limph node enlargement (-)
Thorax : symmetric fusiform, retraction (-)
HR: 90 bpm, reguler, murmur(-)
RR: 22 bpm, reguler, ronchi (-)
Abdomen: soepel, peristaltic (+) normal, ; liver/ spleen
not palpable
Extremities: pulse: 90 bpm, regular, adequate p/v, warm, CRT < 3,
BP : 120/60 mmHg,
 11th May 2016 (3rd day in RSUP HAM)
S Fever (-) , Cough (-),Epigastrium (-),Vomitting (-),Gums bleeding (-),Body Rash (-)
Blackish Feases (-)

O Sens:CM ,Temperature: 37.4 C BW: 50KG

Head :
Eye : light reflex (+/+); isochoric pupil (-/-), pale conjungtiva palpebra (-/-)
Ear: within normal range
Nose : within normal range
Mouth: within normal range
Neck: limph node enlargement (-)
Thorax : symmetric fusiform, retraction (-)
HR: 88bpm, reguler, murmur(-)
RR: 22 bpm, reguler, ronchi (-)
Abdomen: soepel, peristaltic (+) normal, ; liver/ spleen
not palpable
Extremities: pulse: 88 bpm, regular, adequate p/v, warm, CRT < 3,
BP : 120/70 mmHg
A Dengue Hemorragic Fever without Shock

P Bed Rest
IVFD Ringer Laktat 3cc/kgbw/hr = 150cc/kgbw/hr
Close Monitoring of Vital Sign
Complete blood test
 12th May 2016 (4th day in RSUP HAM)
S Fever (-) , Cough (-),Epigastrium (-), Vomiting (-),Gums bleeding (-),Body Rash (-)

O Sens:CM ,Temperature: 36.8 C BW: 50KG

Head :
Eye : light reflex (+/+); isochoric pupil (-/-), pale conjungtiva palpebra (-/-)
Ear: within normal range
Nose : within normal range
Mouth: within normal range
Neck: limph node enlargement (-), neck stiffness (-)
Thorax : symmetric fusiform, retraction (-)
HR: 90bpm, reguler, murmur(-)
RR: 24 bpm, reguler, ronchi (-)
Abdomen: soepel, peristaltic (+) normal, ; liver/ spleen
not palpable
Extremities: pulse: 90 bpm, regular, adequate p/v, warm, CRT < 3,
BP : 120/70 mmHg, Rashes (-)

A Dengue Hemorragic Fever without Shock

P Bed Rest
Discharged
 *
Theory Case
Definition PI is a child with main complaint
Dengue hemorrhagic fever (DHF) : A syndrome continuous fever, spontaneous
due to the dengue virus that tends to affect bleeding gums and body rash for 5
children, causing abdominal pain, hemorrhage days.
(bleeding) and circulatory collapse (shock). DHF
starts abruptly with high
continuous fever and headache plus respiratory
and intestinal symptoms with sore throat, cough,
nausea, vomiting, and abdominal pain. Shock
occurs after 2 to 6 days with sudden collapse,
cool clammy extremities, weak thready pulse,
and blueness around the mouth (circumoral
cyanosis). There is bleeding with easy bruising,
blood spots in the skin (petechiae), spitting up
blood (hematemesis), blood in the stool (melena),
Clinical Manifestation PIs main complaint was high fever as chief

high fever for 2-7 days with temperature complaint.It has been experienced by
patient for the past 5 days before being
of (38-40C)b.
admitted to the RSUP Haji Adam Malik
tourniquet test +, found (purpura)
hospital. Fever has been reduced by
bleedingc. The presence of bleeding in the
paracetamol.
eyelids (conjunctiva), nosebleed There was bleeding in his gums for the past
(epitacsis), 5 day.During the night of the admitted
Faeces with wastes mixed with blood body rash was found around the body.

(melena) Rumple lead test (+)

Blackish colour faeces found (+)
Liver enlargement (hepatomegaly)e.
He also had 5 days history of
Blood pressure decreases
malaise,generalised epigastric pain. There
Trombositopenia and an increase in
was no cough,sore throat, or diarrhea .
hematocrit value 20% of the normal value Patient complained of having headache
(hemoconcentration) and vomiting.
nausea, vomiting, decreased appetite Lab results shows that patient had

(anorexia), abdominal pain, diarrhea, thrombocytopenia.

Normal blood pressure found. Hematocrit
chills, convulsions, and headache
value is in normal range.
Nose bleed and gums
Thus, patient doesnt have shock.
Diagnosis
Clinical criteria: Based on the theory, this patient also
fulfilled some of the clinical and laboratory

1. Sudden Acute Fever 2-7 days2. There criteria to be diagnosed as dengue

hemorrhagic manifestations characterized by:- hemorrhagic fever such as:

Rumple lead test (+)- Petechiae, ecchymosis, Fever past 5 days

purpura- Mucosal bleeding, epistaxis, bleeding Rumple lead test (+)

gums- Haematemesis and melena Laboratory Petechiae was found

criteria:1. Thrombocytopenia (100,000 / mm3 Thrombositopenia was found in lab results.

or less Gums bleeding was found

2. There is at least one sign of plasma leakage as No sign of plasma leakage found because there

follows:- Increased hematocrit> 20% is normal hematocrit value, no pleural

compared to standard according to age and effusion, ascites or hipoprotenemia.

gender.- Decrease hemtokrit> 20% after

receiving fluid therapy, compared with the Thus, with all this criteria found patient is

previous hematocrit values.- Signs of plasma diagnosed with dengue hemorrhagic fever

leakage such as pleural effusion, ascites without shock.

Theraphy PI was given total bed rest.

Bed Rest
Oxygen was not given to the patient because

Oksigen patient doesnt have any difficulties in breathing

IVD NaCl /IVFD Ringer Laktat and his saturation of oxygen was good.
Addition of colloid/ IVFD Ringer Laktat 5cc/kgbw/hour was given on
plasma Dekstran/ the first day. Once the patient was stable and
FPP 10-20 (max 30)
doesnt look weak the IVFD Ringer Laktat was
ml/kg/bb/jam
reduced to 3cc/kgbw/hour.
Whole blood transfusion if
Paracetamol 500mg tab was given whenever the
needed
Anti Emetics
patient had body temperature more than 38.5c.

Paracetamol Same as the theory it states paracetamol is given

when the patient has body temperature more than
38.5c. 10-15mg/kgbw
No blood transfusion given because there is no any
indication of it.
 *
* PI, a boy, 17 years old, with 50kg of BW and 160 cm of Body Height, came to RSUP Haji
Adam Malik Medan on 9th Mei 2016 at 03.00pm with high fever as chief complaint. It

has been experienced by patient for the past 5 days before being admitted to the

RSUP Haji Adam Malik hospital. Fever has been reduced by paracetamol.

Spontaneous bleeding was found. . There was bleeding in his gums for the past 5 day.

Body rash was found around the body. He also had 5 days history of malaise,

generalised epigastric pain. There was no cough, sore throat, or diarrhea . Patient

complained of having headache and vomiting. Patient had blackish feases for 2 days.

DHF cases were reported around patients housing area Patient has been diagnosed

with Dengue Haemorrhagic Fever without shock in a clinic and reffered to Haji Adam

Malik General. Patient was diagnosed with Dengue Hemorrhagic Fever without shock

and treated with IVFD Ringer Laktat 3cc/kgbb, Ranitidin inj and Paracetamol 3 x 500mg

from 9st Mei until 11th Mei. Patient was discharged on 12th Mei 2016 with no sign and

symptoms of DHF.
*