MORNING REPORT

dr.Deddy - IPD

Friday, May 17th 2013

PHYSICIAN IN CHARGE:
I A : dr.Deddy, dr.Asri, dr.Lenny (kardio)
I B: dr.Ella, dr.Aditya
II : dr.Martin
III : Laksmi S., Sp.PD
MODERATOR : dr.Supriono, Sp.PD-KGEH

SUMMARY OF DATA BASE

Female/17 yo/W.28
Chief complaint: Fever
Patient suffered from high grade fever since 4 days ago,
abruptly onset, and subsided when she took paracetamol but after
2 hours the fever was rising again.
Headache since 4 days ago accompanied with myalgia and jpint
fever. No gum bleeding nor nose bleeding.
She complained nausea and vommite 1-2 times per day
contained residual food and water since three days ago.
She went to PHC Bareng two days ago, and diagnose dengue fever
then got therapy paracetamol 3x1 tablet, antacida 3x1 tablet,
vitamin 1x1 tablet.
She had performed blood examination at PHC Bareng with result
trombocyte 91.000, hmt 49, hb 14,4, leucocyte 4.100

PHYSICAL EXAMINATION
BP : 100/60
mmHg

PR : 84 bpm
regular,
strong

General appearance : looked

moderately ill
Looked normoweight

RR : 18 tpm

Tax : 36.5 C
0

GCS 456

Head

Pale conj. -

Neck

JVP R+0 cm H2O

Thorax : Cor

Ictus invisible and palpable at ICS V MCL S

LHM ~ ICS V MCL S, heart waist+
RHM: SL D
S1, S2 single with no murmur

Pulmo

Symmetric, SF D=S

Abdomen

bowel sound N, liver span 10cm, traubes space tympani

Extremities

Rumple Leede +

LABORATORY FINDING
Result

Normal Value

Leucocyte

3.320

/l

:
Hemoglobine

13,2

gr/dl

11.0 16.5

MCV

82,9

Mm3

80-93 fL

MCH

26.70

Pg

27-31 fL

Eos/bas/neu/lim/mo

0/3,3/57,6/33,
4.5,7

PCV

39,4

35 50

Trombocyte

57.000

/L

150.000 390.000

Ureum

14,4

mg/dL 10-50

Creatinine

0,53

mg/dL 0.7 1.5

SGOT

96

U/L

11 41

SGPT

60

U/L

10 41

Anti Dengue IgM

Negative

Anti Dengue IgG

Positive

PPT

11

secon
d

K 11,9 s

APTT

secon

3.500 10.000

CXR (plan for check this morning)

CUE AND CLUE

PL

IDx

Female/17yo
Ax:
-High fever for 4
days , abruptly onset
-Headache, myalgia,
joint pain

1.AFI day
4th+thromb
ocytopenia

1.1.DHF
grade I
1.2.other
arboviral
infection
1.3.Ricketsio
sis

PDx
Weil
Fellix

PE:
Rumple Leede +

PMo

-Diet 2100 kcal/day

-IVFD Asering 5 cc/kgBW
(250 cc) during 1-2 hour
then IVFD Asering 3 cc
/kgBW /hour during 2-4 hour,
maintenance IVFD Asering
2100 cc/24 hour

VS,
Bleedi
ng,
CBC
serial

-Po. Parasetamol 3x500 mg if

Tax>37.5C
-Surface cooling

Lab: PCV 39,4%

Leuco 3.320
Tromb 57.000
Anti Dengue IgG +
SGOT/SGPT: 96/60
APTT 40,8 s (K 25,5
s)
Female/17yo
Ax:
-nausea and
vommite

PTx

2.Dyspepsi
a
syndrome

1.1. dt no 1
1.2.PUD

Inj. Metochlopramide 3x10

mg
PO: omeprazole 2x20 mg

Subj

Condition this morning

GCS 456
Subjective: fever subsided
BP: 100/60 mmHg
HR: 82 bpm, regular, strong
RR: 18 tpm
Tax: 36,1 C

Problem analysis
Dyspepsia syndrome

DHF grade I

Thrombocytopenia

Leucopeni
a
Increase of
transaminase

Bleeding tendency

RISK FACTOR
1. High rural populations in malaria-endemic areas
2. Tropical areas where the disease is common
3. Travelers from non-endemic areas to endemic areas
4. Good nutrition
5. Human activities can create breeding sites for larvae
(standing water in irrigation ditches, burrow pits)
6. Agricultural work such as harvesting (also influenced
by climate) may force increased night time exposure
to mosquito bites

Analysis
1. Emergency: 2. Urgency:

IVFD Asering 5 cc/kgBW (250 cc) during 1-2

hour then IVFD Asering 3 cc /kgBW /hour
during 2-4 hour, maintenance IVFD Asering
2100 cc/24 hour
3. Non urgency:

-Diet 2100 kcal/day

-Surface cooling
-Inj. Metoclopramide 3x10 mg
-PO: -omeprazole 2x20 mg
-parasetamol if Tax>37.5C

THANK YOU

L/O/G/O

Thank You!
L/O/G/O