MORNING REPORT

3rd November 2016

PATIENT IDENTITY
Name

: RFF

Age

: 15 y.o

Sex

: Male

Religion

: Islam

Occupation

: Student

Address

: Sidakarya, South Denpasar

Time of Arrival : 02 November 2016 (16.08 WITA)

ANAMNESIS
CHIEF COMPLAINT

Fever

PRESENT ILLNESS HISTORY

Patient refered to Sanglah Hospital ER from

Puskesmas IV South Denpasar with diagnose DHF gr
III. Patient complaint of fever 4 days prior to admission.
The fever was suddenly high and continous. Fever is
felt throughout the body. Patient complaint of cold
sweat to shivers when fever.
The temperature was reduced after he took the fever
medicine (Paracetamol) but his fever increased again
after that. When the patient admitted to Sanglah
hospital, the fever got better.

ANAMNESIS
Patient also felt nausea and vomiting since 2 days BATH, the
frequency of the vomiting is every time the patient took a meal. Volume
of vomit glass.The patient said that he didnt vomit if the patient
eat breads. Loss of appetitte (+), diarrhoea (-).
Headache (+). This complaint is coincided with fever. Patient said that
Headache such as depressed all over the head. Headache is slightly
better with rest.
Patients also complained of having muscle and joint pain since 4 days
BATH. No bleeding from the gums, petechia, epistaxis

Normal consistency and coloration of stool and urination with normal

frequency.

ANAMNESIS
PAST ILLNESS HISTORY
No history of having the same complaint
before.
History of asthma, hypertension, DM, and
heart disease was denied by the patient.

ANAMNESIS
FAMILY HISTORY
None of his family members have similar
symptoms.
Family history of asthma, diabetes
mellitus, hypertension, and heart disease
was denied.

ANAMNESIS
SOCIAL HISTORY
Patient is a student
None of his friends at school have similar
symptoms or diagnose with DHF.
There is patients neighbour suffer from
DHF and were admitted to hospital

PHYSICAL EXAMINATION
General appearance : moderately ill
Consciousness
: Compos Mentis
GCS
: E4V5M6
Vital Sign:
BP : 80/ palpation
RR : 20x/min
PR : 102 x/min
tax : 36,4C
Body weight
: 54 Kg
Height
: 150 cm
BMI
: 24 kg/m2

STATUS GENERAL
Eyes: Pale (-/-); icterus (-/-) pupillary reaction +/+
isocoric
ENT : Tonsils T1/T1; pharyngeal hyperemia (-);
tongue normal; lip cyanosis (-)
Neck : JVP 0 cmH2O;
lymph node enlargement (-)

STATUS GENERAL
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion
:
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 normal regular, murmur (-)
Po

Inspection : Symetric
Palpation : VF normal/ normal
Percussion
: sonor/sonor
Auscultation : Vesikuler +/+, Rhonchi -/-, Wheezing -/+/+
-/-/+/+
-/-/-

STATUS GENERAL
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Timpani( +)
Palpation : Tenderness on palpation (-);
liver not palpable, spleen not palpable
Extremities: Warm -/-; edema -/-/-/-

COMPLETE BLOOD COUNT

Parameter

01/11/16

02/11/16
(07.52)

Reference range

WBC

4.1
7.0
Abdomen: Insp
: distensi (-)

-Ne
-Ly

-Mo
-Eo
-Ba
RBC

4,1 10,9
50 70

Ausc : Bowel sound (+) normal

27.5
36.7
25 - 40
Palp : H/L not palpable
4.5
8.9
28
tenderness(-)
24
Ballotment (-)
0 1
Perc: Tympani (+)
5.30

7.20

45

HGB

12.9

17.3

12 16

HCT

38.6

- 53.1
-

MCV

73

- 74
-

MCH

24.3

24.0

26 34

MCHC

33.4

32.5

31 36

RDW

15

14.1

11 14.8

115

88

150 440

Extremity: pitting edema

PLT

, warm

40 52
+ +
80 100
+ +

COMPLETE BLOOD COUNT

Parameter

02/11/16
(16.18)

02/11/16
(18.09)

Reference range

WBC

7.63
8.36
Abdomen: Insp
: distensi (-)

-Ne

4,1 10,9

RBC

22.37
50 70
: Bowel
sound (+) normal
32.65
37.17
Palp : H/L not
palpable 25 - 40
35.82
36.57
28
tenderness(-)
0.15
05
0.26
Ballotment (-)
2.09
02
3.63
Perc: Tympani
(+)
6.51
6.08
45

HGB

15.67

-Ly
-Mo
-Eo
-Ba

Extremity:
HCT

29.29
Ausc

14.34

pitting
46.97 edema45.29, warm

MCV

72.14

MCH

24.06

12 16
40 52

+ +

74.51

80 100

23.58

26 34

+ +

MCHC

33.4

31.65

31 36

RDW

15

11.95

11 14.8

43.66

66.25

150 440

PLT

2 NOVEMBER 2016 (16.18)

Parameter
Dengue NS 1 Ag

Hasil

Reference Range

Negatif

Negatif

Ausc : Bowel171.2
sound (+) normal
112.90
Palp : H/L not
palpable
3.7
tenderness(-)
6.00
Ballotment (-)
0.55
Perc: Tympani
(+)

11.00-33.00

127

136-145

Abdomen: Insp : distensi (-)

SGOT
SGPT
-Albumin
-BUN
-Kreatinin
Na
K

Extremity: pitting edema

4.4, warm

11.00-50.00
3.50-5.20

8-23
0.70-1.20

+ +

3.5-5.1

PPT

- 13.7
-

INR

1.12

0.9-1.1

35.80

24-36

APTT

+ +10.8-14.4

ASSESSMENT

Suspect Dengue Shock

Syndrome Day - 4

THERAPY
Hospitalized
IVFD RL 20 ml/kgBW (1080 cc)
10ml/ kgBW (540 cc)
7 ml/kgBW (380 cc)
5 ml/kgBW (270 cc)
3ml/kgBW (160 cc) RL 30 tpm
Paracetamol 3 x 500mg I.O
Drink water 1,5-2 L daily

PLANNING DX

CBC
DHF Serology day VII

MONITORING
Complaints
Vital Sign
Fluid Balance
CBC @ 12 hours

THANK YOU

OBSERVATION
TIME

GCCS

BLOOD
PRESSURE

PULSE
RATE

CM

CK

17.00

E4V5M6

100/60

108

1000 cc

1200 cc

17.30

E4V5M6

110/60

106

1300 cc

1200 cc

18.00

E4V5M6

90/70

108

1500 cc

1300cc