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Morning Report

February 16 ,
th 2015
Patient Identity
Name : KDF
No CM : 15009387
Sex : Male
Age : 13 y.o
Status : Single
Religion : Islam
Nationality : Indonesia
Address : Jl. Pulau Halmahera
Weight : 60kg
Anamnesis
Chief Complaint: Fever
Present History:
Patient came with complaints of fever since 6 days before
administered to hospital (Tuesday, February 10th 2015). The fever
was suddenly occurred high. But the fever was not measured by the
patient or the patients family.
Patient has consumed paracetamol by the onset of fever, and the
fever decreased.
Theres no complain about headache and muscular pain
Patient also complained nausea and vomitting since 4 days before
administered to hospital (Thursday, February 12h 2015). The nausea
and vomitting induced by food administration (porridge). Blood in
vomit declined by patient. No problem in drinking found.
Theres no complaint on epistaxis, gum bleeding, urination and
defecation
History of taking medicine
Paracetamol tablet (500 mg)
Past History
Patient never had the same symptoms like this
before.
Family History
None of family members have similar symptoms
Sosial History
History of smoking, using drugs and
consuming alcohol was denied by the patient
Physical Examination
Vital Sign
General condition : Moderately ill
Conciousness : Composmentis
(GCS: E4V5M6)
Blood Pressure : 120/80 mmHg
Heart Rate : 80 x/minute
Respiration Rate : 22 x/minute
Temp. Axilla : 36,8oC
Status General
Eye : Anemis (-/-), icterus (-/-)
oedema palpebra (-/-), pupil reflex (+/+)
isocoric
ENT :
Ear : within normal limit
Nose : within normal limit
Throat : within normal limit
Neck :
Thyroid and Lymph node : no enlargement
Thoraks:
Cor
Inspection : Iktus kordis unseen
Palpation : Iktus kordis not palpable
Percussion : RB : Right Para Sternal Line
LB : Left Mid Clavicular Line
ICS V
UB : ICS II
Auscultation : S1 S2 single, regular, murmur -
Thoraks:
Pulmo
Inspection : Symetric on static and dynamic
Palpation : Vocal Fremitus N/N
Percussion : Sonor/sonor
Auscultation : Vesicular +/+ , Rhonki -/-,
Wheezing -/-
Abdomen :
Inspection : Distention (-)
Auscultation : Bowel Sounds (+) N
Percussion : Timpani (+)
Palpation : Hepar and lien not palpable
Pain : -
Knock pain CVA : -/-
Ekstremities: Warm +/+, edema -/-
+/+ -/-
Laboratory Result ( February 16th 2015)
Parameter Result Reference range Unit
WBC 2.72 4.1 11.0 10^3/L
#NE 0.664 2.5 7.5 10^3/L
#LY 1.42 1.0 4.0 10^3/L
#MO 0.601 0.1 1.2 10^3/L
#EO 0,015 0.0 0.5 10^3/L
#BA 0,20 0.0 0.1 10^3/L
RBC 6.81 4.50 5.90 10^6/L
HGB 17.7 13.5 17.5 g/Dl
HCT 54.4 41.0 53.0 %
MCV 79.9 80.0 100.0 fL
MCH 26.0 26.0 34.0 Pg
MCHC 32.5 31.0 36.0 g/dL
RDW 12.7 11.6 14.8 %
PLT 32.6 150 440 10^3/L
MPV 12.4 6.8 10.0 fL
Laboratory Result ( February 16th 2015)

Parameter Result Reference range Unit


SGOT 171.4 11-33 U/L
SGPT 133.2 11.00-50.00 U/L
Albumin 4.61 3.50-5.20 gr/dl
BUN 18 8.00-23.00 mg/dL
Creatinin 0,86 0.70-1.20 mg/dL
Natrium (Na) 130 136-145 mmol/L
Kalium (K) 5.39 3.50-5.10 mmol/L
Assessments
Susp. Dengue Infection day 6 with warning
sign
Hemoconcentration
Management
Therapy :
Hospitalized
IVFD RL
Loading 7cc/kgBB (420cc) -> 5cc/kgBB (300cc)
-> 3cc/kgBB (180cc) -> RL 30 tpm
Free diet
Paracetamol 3 x 500mg i.o
Drink water 1.5-2 L/day
Planning :
SEROLOGY DHF (IgG and IgM anti dengue)
day 7
CBC every 8 hours
CBC post loading

Monitoring :
Monitoring vital sign, complaints
CBC Post Loading
Parameter Result Reference range Unit
WBC 1.80 4.1 11.0 10^3/L
#NE 0.483 2.5 7.5 10^3/L
#LY 0.589 1.0 4.0 10^3/L
#MO 0.651 0.1 1.2 10^3/L
#EO 0,016 0.0 0.5 10^3/L
#BA 0,060 0.0 0.1 10^3/L
RBC 5.94 4.50 5.90 10^6/L
HGB 15.8 13.5 17.5 g/Dl
HCT 48.1 41.0 53.0 %
MCV 80.9 80.0 100.0 fL
MCH 26.5 26.0 34.0 Pg
MCHC 32.8 31.0 36.0 g/dL
RDW 12.9 11.6 14.8 %
PLT 38.7 150 440 10^3/L
MPV 10.8 6.8 10.0 fL
THANK YOU