DUTY REPORT

20
th
AUGUST 2014
GP on duty : dr. Sere & dr. Arlis
Co-ass on duty : Alvin & Dessy

PATIENTS RECAPITULATION
In patient :
- Nn. R (DHF) our patient
- Tn. B (pneumonia) Dead
-Tn. U (dyspnoe observation)
- Tn. A (suspect stroke hemorrhagic)
- Ny. W (Gastritis)
- Tn. D (lung carcinoma with metastasis to back bone)
- Ny. W (hemoptysis)
- Ny. F (dyspepsia syndrome)
- Ny. S (Congenital Heart Failure)
- Tn. D (Low intake and loss of consciousness)
- Tn. H (pain on the right chest)
Out patient :
- Tn. A (sinusitis)
- Tn. J (syndrome dyspepsia)
- Tn. F ()
Total patient : 15


PATIENTS IDENTITY
Name : Ms. RF
Sex : Female
Place, Date of Born : Jakarta, February 7
th
1993
Age : 21 years old
Job : Student
Religion : Moslem
Marital Status : Single
Ethnic/Race : Javanese
Address : Jl. Kayu Manis VIII, Matraman


History of Present Illness
Chief complaint : Patient came to ER with chief complaint of
fever 5 days before admission.

The fever doesnt have a specific time, and it goes fluctuating
every day, had given drugs for her fever and she felt better, but
after 4 hours, the fever came again. She had a complain of her
arm and leg with a red spots from 3 days before admission. The
red spots doesnt diminished until she came to the hospital. She
had an episode of gum bleeding spontaneously and when she
flossed her teeth. She complained that she had red spots in both
of her arms and legs. She still wants to eat and drink by herself.
She doesnt have any complain like palpitation, excessive
sweating, abnormal breathing.
Patient had a history of sore throat 5 days before admission, with
no cough, and no symptoms of flu

No history of travelling to Kalimantan or Papua, flood areas, no
history of rat bite.

No history of diarrhea, she had no complaint in urinating and no
complain in defecation. She didnt have any complain of black
stool.

History of Past Illness
She didnt have any history of high blood pressure,
diabetes, and no history of heart disease, lung and
renal disease.
She never experienced these symptoms before
History of family illness
She doesnt have any history of high blood pressure,
diabetes and malignancy.
No family members have the similar symptoms


History of Socio-Habits
She neither smokes, drinks alcohol, nor uses any
forbidden drug.
She could still eat and drink well
Physical Examination
General State : Mildly sick
Consciousness : fully alert

Vital Signs
Blood Pressure : 90/60 mmHg
Heart rate : 88 bpm
Respiratory Rate : 18 times/minute
Temperature : 37.3
o
C

Body Weight : 54 kg
Body Height : 164 cm
BMI : 20.07 (Normoweight)

General Examination
Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric sclera (-/-)
Ears : discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : coated tongue (-), hyperemic pharynx (-), normal T1-T1,
pale mouth mucosa (-), dried mucosa (-)
Neck : lymph nodes enlargement (-)


Thorax: symmetric, intercostals retraction (-)
COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dekstra
Left border : ICS V, linea midclavicularis sinistra
Heart waist: ICS IV, linea parasternal sinistra
Auscultation : regular 1
st
and 2
nd
heart sound, murmur (-),
gallop (-)


PULMO
Inspection : chest within normal shape, symmetries on static and
dynamic state
Palpation : tactile vocal fremitus both lungs were symmetries, chest
expansion symmetries
Percussion : resonant both lungs
Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

Abdomen : flat, not distended,
timpani, no enlargement of liver & spleen
Extremities : warm, petechiae on extremities (+), CRT < 2 seconds,
torniquet test (+)

Laboratory Results
(20/08/2014)
Hemoglobin: 12,8 g/dL
Hematocrite : 38%
Erytrocyte : 4.66
Leukocyte : 2670
Platelet : 82.000
MCV : 82.2
MCH : 27.5
MCHC : 33.4




RESUME
Ms. RF, 21 years old, came to ER with the chief complaint of fever 5
days before admission. The fever doesnt have a specific time. She was
given drugs for her fever and she felt better, but after 4 hours, it was
recurrent. She complained of red spots around her arms and legs. The red
spots did not disappeared until she came to the hospital. She had an episode
of spontaneous gum bleeding when she flossed her teeth. She still wants to
eat and drink by herself though.

Physical examination showed remarkable sign in both her legs and
arms with spontaneous ptechieae, and torniquet test (+)
Laboratory results showed WBC 2670, Platelet 82.000/uL.

Diagnosis
Working diagnosis
DHF grade II

Differential diagnosis
Upper resp. tract infections
Malaria
leptospirosis
List of Problem
DHF grade II
Discussion
DHF grade II, Based on: (WHO 1997)
HT and PE:
history of sudden fever 2 7 days, biphasic
One or more than bleeding manifestation:
Tourniquet test (+) > 20 petechiae within 2,54 cm
2
Ptecheiae, ecchymoses, or purpura
Mucosal bleeding, GI bleed or others
Hematemesis or melena
Lab:
Thrombocytopenia ( < 100.000/mm
3
) 82.000/mm3
One or more plasma leakage signs:
HCT > 20% compare to average HCT in ages, gender and
population
HCT < 20% from baseline HCT after fluid therapy
Evidence of pleural effusion, pericard effusion, ascites and
hypoproteinemia
Dengue fever grading
Grade I: Fever with untypical constitutional symptoms,
bleeding manifestation (+) by tourniquet test

Grade II: Grade I with spontaneous bleeding

Grade III: Compensated DSS (characterized by tachy- or
bradycardia or hypotension, with cold skin and
agitated)

Grade IV:Uncompensated DSS (characterized by irregular
blood pressure and heart rate)
Plan and Treatment
Non-pharmacological
interventions:
Bed rest
Oral fluid intake
max. 2L/day
Diet 1728 calories
Pharmacological
interventions:
IVFD RL 500 cc / 4
hours
Paracetamol tab. 500
mg, q8hr (On-
demand)
Diagnostic plans:
IgM IgG anti
dengue

Monitoring plans:
CBC q24hrs
SGOT/SGPT
Ureum/Creatinine
Urine output
Random blood
sugar
Prognosis
Quo ad Vitam : ad bonam
Quo ad Functionam : ad bonam
Quo ad Sanationam : dubia ad bonam
THANK YOU