CHAPTER II CASE REPORT

II.1. IDENTIFICATION
Name Sex Age Address Status Occupation Religion : : : : : : : Mr. A M Male 16 Years Old Jl. Robani Kadir Lr. Nurul Huda Kelurahan Talang Putri, Plaju, Palembang Single Student Moslem Desember 9th 2008

Admitted to hospital :

II.2. ANAMNESIS (Autoanamnesis) Chief of complain Nasal bleeding since 1 day before admitted to hospital History of illness
6 days before admission, patient complained of having fever, intermitten, shaking chills sometimes (+), headache (+), retrorbital pain (-), fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain (-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination. Patient wasnt going anywhere to take medication for these complaints. 3 days before admission, fever decreased, headache (+), retrorbital pain (-), fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (-), stomach pain (-), decrease of appetite (+), cough (-), cold (-),there was no disorder in defecation and urination, patient complained about rash spread on the chest and trunk, rash was itchy. Patient use baby powder to decrease the itchy. 1 day before admission, the fever increased, intermitten, shaking chills sometimes (+), headache (+), retrorbital pain (-), fatigue (+), joint and skletal pain (+), nose bleeding (+), gum bleeding (+), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain

(-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination. Patient complained about rash spread to hand and face, itchy (+), patient went to the Muhammadiyah Hospital but, he was reconciled to the Mohammad Hoesin Hospital.

History of past illness History of Malaria fever was denied History of Thypoid fever was denied History of Dengue fever was denied History of going to endemic area was denied

History of family disease History of chicken pox disease on his neighbour.

II.3 PHYSICAL EXAMINATION o General examination

General condition Sickness condition Consciousness Blood pressure Pulse rate Respiration rate Temperature Dehydration
Weight Height

: sick : moderate sickness : compos mentis : 110/70 mmHg : 80 times/minute, regular : 20 times/minute : 37,3 0 C : (-) : 48 kg : 162 cm : RBW = 86% Impressive: Underweight

Nutrition

Spesific examination 1. Skin

 Skin color is puce Normal pigmentation Efloresence, black spot on some places. Scar (-) Hyperhidrosis (-) Normal hair growth Good turgor Wet or dry in palpitation (-) Nodul subcutan (-) 2. Lymph gland There were no enlargement of the lymph nodes on submandibular, neck, axillaries and inguinal. 3. Head 4. Eye 5. Nose Epistaxis (+) Normal nasal septum and mucous layer Eksophtalmus and enophtalmus (-) Edematous palpebra superior (-) Pale of conjunctiva palpebra (-) Sclera icteric (-) Oval, symmetrical Puffy face (-) Deformity (-) Malar rash (-) Alopecia (-)

6. Ear Good hearing Normal both of meatus accusticus externus

7. Mouth Typhoid tongue (-) Rhagaden of lips (-) Stomatitis (-) Papil atrophy (-) Gum bleeding (+)

Fetor oris (-) 8. Neck Thyroid gland not palpable, thyroid bruit (-) Jugular vein pressure (5-2) cmH20 Hypertrophy of musculus sternocleidomastoideus (-), stiffness (-) 9. Thorax Normal shape Extended intercostal section (-) Retraction (-) Venectasis (-) Spider naevi (-) 10. Lung Inspection Palpation Percussion : symetrical of static and dynamic right and left are equal : stemfremitus right and left are equal : sonor both of the lung

Auscultation : Vesiculer (+) N, Ronchi (-), Wheezing (-)

11. Cor Inspection Palpation Percussion Auscultation 12. Abdomen Inspection Palpation Percussion Auscultation 13. External genitalia : not examined 14. Upper extremity Pain on joint (+) Pale on finger (-) Erythema of palm (-) : flat, venectation (-), : Pain (-) , liver and lien are unpalpable : tympany, shifting dullness (-) : bowel sound (+) normal : ictus cordis not seen : ictus cordis not palpable : upper boundary of cor is ICS III, left boundary of cor is linea mid : HR (80 x/m), Murmur (-), Gallop (-)

clavicula sinistra, right boundary of cor is linea sternalis dextra

Rumplee leed (-) Pitting edema (-) Clubbing finger (-) Tremor (-) Normal physiological reflex

15. Lower extremity Varices (-) edema (-) Pain on joint (+)

 Pale on finger (-) Normal physiological reflex

II.4 ADDITIONAL EXAMINATION Laboratory Findings (Desember 9th 2008) First examination (22.00pm)

Blood analysis o Hemoglobin o Hematocrite o Trombocyte o Leucocyte o LED o Diff. Count

: 13,2 g/dl : 38 vol% : 25.000/mm3 : 8.900 / mm3 : 13 mm/hours : 0/3/0/64/30/3

( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 5000-10000/ mm ) (<15 mm/hours) ( N: 0-1/1-3/2-6/50-70/20-40/2-8 )

Laboratory Findings (Desember 10th 2008)

Blood analysis
First examination (03.00pm)

o Hemoglobin o Hematocrite o Trombocyte o Hemoglobin o Hematocrite o Trombocyte o Protein total o Albumin o Globulin

: 11,4 g/dl : 34 vol% : 19.000/mm3 : 11,4 g/dl : 34 vol% : 19.000/mm3 : 51 g/l : 31 g/l : 20 g/l

( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm )

Second examination (09.00 pm)

o Fosfatase Alkali: 45 U/I o SGOT o SGPT : 20 U/I : 11 U/I

Third examination (15.00 am) o Hemoglobin o Hematocrite o Trombocyte o Hemoglobin o Hematocrite o Trombocyte : 10 g/dl : 30 vol% : 22.000/mm3 : 9,6 g/dl : 28 vol% : 30.000/mm3 ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm )

Fourth examination (21.00 pm)

Urine Analysis o Epithelial cell o WBC o RBC o Cylinder o Crystal o Protein o Glucose o Nitrit

: (+) : 2-3/LPB : 0-1/LPB : (-) : (-) : (-) : (-) : (-) ( N: 0-5/LPB ) ( N: 0-1/LPB ) ( N: - ) ( N: - ) ( N: - ) ( N: - ) ( N: - )

Laboratory Findings (Desember 11th 2008) First examination (03.00pm)

Blood analysis o Hemoglobin o Hematocrite o Trombocyte o Hemoglobin o Hematocrite o Trombocyte : 12,7 g/dl : 36 vol% : 34.000/mm3 : 11,6 g/dl : 34 vol% : 25.000/mm3 ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm )

Second examination (09.00 pm)

Third examination (15.00 am) o Hemoglobin o Hematocrite o Trombocyte o PT o APTT Urine Analysis o Epithelial cell o WBC o RBC o Cylinder o Crystal o Protein o Glucose o Darah/Hb o Nitrit : (+) : 3-4/LPB : 100/LPB : (-) : (-) : (+) : (-) : (+) : (-) ( N: 0-5/LPB ) ( N: 0-1/LPB ) ( N: - ) ( N: - ) ( N: - ) ( N: - ) ( N: - ) ( N: - ) : 10,6 g/dl : 30 vol% : 33.000/mm3 : 14,3 : 33,3 ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm )

Laboratory Findings (Desember 12th 2008) First examination (03.00pm)

Blood analysis o Hemoglobin o Hematocrite o Trombocyte o Hemoglobin o Hematocrite o Trombocyte o Hemoglobin o Hematocrite o Trombocyte : 10,5 g/dl : 30 vol% : 14.000/mm3 : 10,5 g/dl : 31 vol% : 42.000/mm3 : 10,1 g/dl : 31 vol% : 32.000/mm3 ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm ) ( N: 14-18 g/dl ) ( N: 40-48 vol% ) ( N: 200000-500000/ mm )

Second examination (09.00 pm)

Third examination (21.00 am)

II. RESUME

A man initialed name Mr. AM, 16 years old, admitted to hospital in November 9th 2008, with rash in whole of body since 1 day before admitted to hospital
6 days before admission, patient complained of having fever, intermitten, shaking chills sometimes (+), headache (+), joint paint (-), retrorbital pain (-), fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain (-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination. Patient wasnt going anywhere to take medication for these complaints. 3 days before admission, fever decreased, headache (+), joint paint (-), retrorbital pain (-), fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (-), stomach pain (-), decrease of appetite (+), cough (-), cold (-),there was no disorder in defecation and urination, patient complained about rash spread on the chest and trunk, rash was itchy. Patient use baby powder to decrease the itchy. 1 day before admission, the fever increased, intermitten, shaking chills sometimes (+), headache (+), joint paint (-), retrorbital pain (-), fatigue (+), joint and skletal pain (+), nose bleeding (+), gum bleeding (+), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain (-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination. Patient complained about rash spread to hand and face, itchy (+), finally patient went to RSMH for medication. The neighbour of the patient has history chicken pox disease. From physical examination, the general condition of the patient was moderate sickness and his consciousness was compos mentis. Blood pressure 110/70 mmHg, pulse rate 80 times/minute, reguler, respiration rate 20 times/minute, temperature 37,3 0C, RBW (weight = 48 kg and height = 162 cm) = 86%, impressive underweight, jugular vein pressure (5-2) cmH2O. Normal thorax, While abdomen examination, pain on epigastrium (-), liver and spleen is unpalpable, and skin, there was Efloresence, black spots on some places.

II.6 WORKING DIAGNOSIS Dengue Haemorrhagic Fever grade II + Varicella II.7 DIFFERENTIAL DIAGNOSIS o o Typhoid fever Viral acute infection

II.8 TREATMENT Nonpharmachology Bed rest Diet BB

Pharmachology IVFD Rl gtt XL/menit Cefotaxim 2x1 gr Domperidon 3x1 tab Salicyl talc Vit. B1, B6, B12 3x1 tab Paracetamol 500 mg (prorenata)

II.9 PLANNING Routine Blood analysis Hb, Ht, trombocyte every six hours

II.10 PROGNOSIS Quo ad vitam Quo ad functionam : Bonam : Bonam

II.11 FOLLOW UP
S December 10th 2008 complaint : headache (+), nose bleeding (+), gum bleeding (+) Sense O Blood pressure Temperature Head Neck Cor Pulmo Abdomen Compos mentis 110/70 mmHg 36.5 C Pulse rate Respiration rate 80 x/menit 20 x/menit

Pale of conjunctiva palpebra (-), icteric sclera (-) JVP = (5-2) cmH20, Lymph gland enlargement (- ) HR = 80 x/min, regular, murmur (-), gallop (-) vesicular (+) N,Ronchi (-), wheezing (-) Flat, pain (-) on epigastrium, liver and spleen are unpalpable, bowel sound (+) normal

Extremitas A P

Edema (-)

DHF grade II + varicella Nonpharmachology Bed rest Diet BB Pharmachology IVFD Rl gtt XL/menit Cefotaxim 2x1 gr Domperidon 3x1 tab Salicyl talc Vit. B1, B6, B12 3x1 tab Paracetamol 500 mg (prorenata)

 Trombocyte transfusion 10 bags PT, aPTT examination

December 11th 2008 complaint : headache (+), nose bleeding (+), gum bleeding (+), hematuria (+) Sense Compos mentis 110/70 mmHg 37C Pulse rate Respiration rate 80 x/menit 20 x/menit

Blood pressure Temperature Head Neck Cor Pulmo Abdomen

Pale of conjunctiva palpebra (-), icteric sclera (-) JVP = (5-2) cmH20, Lymph gland enlargement (- ) HR = 88 x/min, regular, murmur (-), gallop (-) vesicular (+) N,Ronchi (-), wheezing (-) Flat, pain (-) on epigastrium, liver and spleen are unpalpable, , bowel sound (+) normal

Extremitas A P

Edema (-)

DHF grade II + varicella Nonpharmachology Bed rest Diet BB pharmachology IVFD Rl gtt XL/menit Cefotaxim 2x1 gr Domperidon 3x1 tab Salicyl talc

 Vit. B1, B6, B12 3x1 tab Paracetamol 500 mg (prorenata)

December 12th 2008 complaint : nose bleeding (+), gum bleeding (+), hematuria (+) Sense Compos mentis 110/70 mmHg 36,5 C Pulse rate Respiration rate 80 x/menit 18 x/menit

Blood pressure Temperature head neck Cor Pulmo Abdomen

Pale of conjunctiva palpebra (-), icteric sclera (-) JVP = (5-2) cmH20, Lymph gland enlargement (-) HR = 80 x/min, regular, murmur (-), gallop (-) vesicular (+) N,Ronchi (-), wheezing (-) Flat, pain (-) on epigastrium, liver and spleen are unpalpable, bowel sound (+) normal

Extremitas A P

Edema (-)

DHF grade II + varicella Nonpharmachology Bed rest Diet BB Pharmachology IVFD Rl gtt XL/menit Cefotaxim 2x1 gr Domperidon 3x1 tab Salicyl talc

 Vit. B1, B6, B12 3x1 tab Paracetamol 500 mg (prorenata)

December 13th 2008 complaint : (-) Sense Compos mentis 120/80 mmHg 36,5 C Pulse rate Respiration rate 78 x/menit 22 x/menit

Blood pressure Temperature head neck Cor Pulmo Abdomen

Pale of conjunctiva palpebra (-), icteric sclera (-) JVP = (5-2) cmH20, Lymph gland enlargement (- ) HR = 80 x/min, regular, murmur (-), gallop (-) vesicular (+) N,Ronchi (-), wheezing (-) Flat, pain (-) on epigastrium, liver and spleen are unpalpable, bowel sound (+) normal

Extremitas A P

Edema (-)

DHF grade II + varicella Nonpharmachology Bed rest Diet BB Pharmachology IVFD Rl gtt XL/menit Cefotaxim 2x1 gr Domperidon 3x1 tab Salicyl talc

 Vit. B1, B6, B12 3x1 tab Paracetamol 500 mg (prorenata) Repeat DDR analysis