DHF GRADE I

BY:
ARYA MAHESWARA WARDHANA M, MD
SUPERVISOR:
M. DIANA RAHIM, MD
PATIENT IDENTITY

Ny. S/25 years old/182406

Jun 09 2022/22.15
GP : Faisyal Herlana, MD
COURSE OF DISEASE

Patient come to emergency room of Guntur hospital with the complains of fever since 5 days ago.
Fever felt persistent. Patient also complain nausea, vomitus 1x/days, tummyache since 6 days, cough
since 2 days, dry cough no phlegm. Bleeding (-), Previously the patient treated at the Cibatu Public
Health Centre. Defecate and urination normal.
Disease history (-)
History of drug use (-)
PHYSICAL EXAMINATION

General Condition : moderately illness

Awareness : Compos Mentis
GCS : 15
Tension : 100/60 mmHg
Pulse Rate : 104 x/minute
Respiratory Rate : 21 x/minute
Temperature : 35,7 C
Oxygen Saturation : 98% free air
PHYSICAL EXAMINATION

Head
Eyes : anemic conjungtiva -/-, icteric sclera -/-
Nose : nostring breathing (-)
Mouth : cyanosis (-)
Neck : lymph node enlargment (-)

Thorax : symmetrical chest movements

Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : vesicular breath sounds , crackles -/-, wheezing -/-
PHYSICAL EXAMINATION

Abdomen : flat, soepel, bowel sound (+) normal, tenderness (+) a/r epigastric
Liver : within normal limits
Spleen : within normal limits

Extremities :
warm, CRT <2 seconds, Edema (-), ptechie (+) a/r fossa cubity dextra and
sinistra
SUPPORTING EXAMINATION
LABORATORY EXAMINATION
(June 09 2022)

 Blood routine
- Hb : 16,6 gr/dL
- Leukocyte : 8600/mm3
- Trombocyte : 45.000/mm3
- Ht : 52,4
- Diff Count : 0/2/3/37/31/27
 Immunology
Rapid antigen Covid-19 : Negative
DIAGNOSE

DHF GRADE I
MANAGEMENT

 IVFD RL 20 dpm Advice dr.Ferry, Sp.PD

 Inj. Omeprazol 1x40 mg IV • Acc non-isolation ward
 Inj. Ondansetron 2x4 mg IV
• IVFD RL 30 dpm
 Pct 3x500 mg PO
• Inj. Lefos 1x500mg PO
 Dehaf 3x1 sach PO
 Siladex 3x1 cth PO
FOLLOW UP
June 10 2022 June 11 2022 June 12 2022

Fever up and down, tummyache (+), Fever reduced, tummyache (-), red
Fever reduced, tummyache (+), red spots
Subjective red spots (+), arthralgia (-), nausea spots reduced
reduced
(-), vomit (-), cough (+)
Tension : 121/88 mmHg Tension : 119/87 mmHg
PR : 95 x/m PR : 95 x/m
Tension : 120/85 mmHg
RR : 20 x/m RR : 20 x/m
PR : 93x/m
T : 36,2 C T : 36,1 C
RR : 20 x/m
SpO2: 97% FA SpO2: 96% FA
T : 36,4 C
Objective Abdomen : tenderness a/r epigastric Abdomen : tenderness a/r epigastric
SpO2: 98% FA
Extremities : ptechie a/r fossa cubity Extremities : ptechie a/r fossa cubity dex-
Abdomen : tenderness a/r
dex-sin sin
epigastric (-)
Lab result : Lab result :
Trombocyte: 32.000 Trombocyte: 72.000
Hematocrit : 45,9% Hematocrit: 41,6%

DHF grade I
IVFD RL 20 dpm
Inj. Omeprazol 1x40 mg IV
Diagnose and Inj. Ondansetron 2x4 mg IV
Planning Pct 3x500 mg PO
Dehaf 3x1 sach PO
Siladex 3x1 cth PO
Lefos 1x500mg PO
June 12 2022

 Advice dr Feri Sp.PD

-Patient can go home
Tx:
Dehaf 3x1 sach PO
Lefos 1x500mg PO