CLINICAL CONFERENCE

INFECTION DIVISION
(New Case)
JUNE 21nd 2021

dr. Sukma Susanti/ Presenter

dr. Akhmad Ihsan, dr. Apriani Aridan/ Senior
 PATIENT IDENTITY
MM, 17 years (Male)
MR Number 937956
Date of Birth July 22th, 2003
Admission Date April 18th, 2021

MEDICAL DIAGNOSIS
Infection Division :
Dengue Fever
PATIENT PICTURE
 HISTORY TAKING
Main Complaint
Fever since 5 days ago

History of Present Illness

 A boy, 17 years come to the hospital with chief complain fever since 5 days
( 6th day of illness ) before admitted to the hospital. The fever continously,
decreased with antipiretic drug. No Seizure. there was vomitting since 10
hours before admitted to the hospital, frequent 2 times, not projectil, consist
of food and drink.
no cough, no shortness of breath.
 Urination was normal
Defecation: not today, history of diarrhea 4 days ago with a frequency of 4
times, no mucus and blood
There is a history of people around the neighborhood suffering from
dengue fever
 No histrory of epistacsis, gum bleeding, melena and red color
urination

Vital Sign
GCS15 (E4 M6 V5)
Blood Pressure : 100/60 mmhg
Heart Rate : 94 bpm
Temperature : 36.8 °C
Respiration Rate : 20 times/min
Pain Scale : 0 NRS
SpO2 : 98 %
PHYSICAL EXAMINATION
Antropomethry
Body weight : 49 kg
Length : 165 cm
Head Circumference : 51,5 cm (Normal 49,5-55,5 cm)
Weight for Length : 34/30x 100% = 113% (overweight)
Weight for Age : 34/30x 100% = 113 % (normal)
Length for Age : 136/136 x 100% = 100 % (normal)
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION
History of Vaccine
Vaccine 1 2 3 4 Mark
HB √ √ √ √
BCG √
DPT √ √ √
POLIO √ √ √ √
MR / CAMPAK √

OTHER

History of Growth and Development

Observe the hand : forget One syllables : Forget
Grabbing object : Forget Pointing the object : forget
Prone position by self : forget First tooth : Forget

Head And Neck
No pale, no jaundice
no stomatitis
No lymphadenopathy
Farynx : No hyperemis
Tonsil : T1-T1 No Hyperemis
Chest and pulmo
Vesicular breath sounds.
No rales , no wheezing
Cardiovascular
I / II heart sound, Regular rhythm
no murmur
PHYSICAL EXAMINATION
Abdomen
No distension, turgor normal
Normal peristaltic sound
Hepar and spleen were not palpable
No Ascites
Extremity :
No edema, no wasting, CRT < 2 seconds
Other :
No Spontaneus Bleeding Menifestation
Rumple leede test : negative
 LABORATORY FINDING
15-6-2021
Laboratory Normal Value
(Wahidin Hospital)

Hb 17,3 12.0 – 16.0 gr/dL

WBC 3.100 4.0 – 10.0 x 103/μL

PLT 24.000 150 - 400 /mm3

MCV 86 80 -100 μm3
MCH 31 27 - 32 Pg
HCT 48 37-48 %
NEUT 30.1 52-75 %
LYMPH 51,1 20-40%
MONO 17,5 2-8 10^3/UL
 LABORATORY FINDING
15-6-2021
Laboratory (Wahidin Normal Value
Hospital)
Random Blood
113 140 – 200 mg/dl
Glucose
Natrium 132 135-145 mmol/L
Kalium 4,1 3,5 - 5,1 mmol/L
Chlorida 99 97-111 mmol/L
SGOT / SGPT 167/54
 Assesment
- Dengue fever
- Hyponatremia
 Planning
Ringer lactat 5cc/BW/Hours
Natrium correction :
(Delta Natrium x 0,6 x BW) x Natrium daily
= ((135-132)x0,6x49) + 2 X 49
= 189 meq
Fullfiled with Ringer's lactate infusion of 5cc/BW/Hours
Paracetamol injection 10mg/kgbb = 500mg/8 hours/intravenous
Drink enough
Routine blood test/day
 Observasion vital sign
THANK YOU