CASE REPORT –

A GIRL WITH DENGUE HEMORRHAGIC FEVER GRADE II

Supervisor :
Zahra Afifah Hanum G99172162
dr. Annang Giri Moelyo, Sp.A
Khoirunnisa G99181038
(K), M.Kes

1
PATIENT STATUS
2
PATIENT IDENTITY
 Name : Child A
 Date of birth : February, 21st 2015 (3 years 6 months)
 Sex : Female
 Address : Klingkingan, Sedayu, Jumantono, Karanganyar
 Weight : 14 kg
 Height : 97 cm
 Date of admission : February, 20th2019
 Date of examination : February, 22nd 2019

3
HISTORY TAKING
 Chief Complain
Fever
 3 days before
Fever appeared suddenly and all day long. Patient really fussy and
don’t want to eat. And then the parents bring the patient to a clinic
and given paracetamol syrup by the doctor. But the fever was stayed,
so the next day patient brought back to the clinic and given
anitibiotics.
 1 day before
The parents bring the patient to a hospital in Solo then referred to
Moewardi hospital. Before arrived at Moewardi hospital, patient got
vomiting with blood once, half a glass. Patient got nosebleed too with
a small amount and bleeding stops spontaneously. Trauma history was
denied. Patient also got headache, stomachache, joint pain

4
HISTORY TAKING
 At the Emergency Room of Moewardi Hospital
Patient still got fever, headache, stomachache, and nosebleed for
the second time. History of cough, cold, pain on ears, pain while
urination or defecation was denied. History of seizures was denied
too.

5
HISTORY OF RECENT ILLNESS
 History of similar problem : Yes
Got DHF 6 months ago, treated at the hospital for 8 days

 History of seizures : Denied

 History of cardiac disease, allergy : Denied

6
HISTORY OF FAMILY ILLNESS
 History of family illness
• History of similar problem : Denied
• History of allergic : Denied
 History of socio-economic
• Patient’s neighboor also had DHF and referred to hospital
• The father work as factory worker on the other city
• The mother work as housewife
• Patient seek treatment using class I BPJS

7
HISTORY OF PREGNANCY AND BIRTH
 History of pregnancy
• Pregnant when she was 28 years old (G1P1A0)
• History of fever, bleeding, and other illness were denied
• Routine to check her pregnancy to the midwife and receive
vitamin and supplements
 History of birth
• Patient birth normally (pervaginam) and aterm
• Birth weight 3200 gram and the length was 49 cm
• Cried spontaneously, not blue, not yellow, moving actively

8
HISTORY OF IMMUNIZATION
 0 months : Hep B
 1 months : BCG, Polio 1
 2 months : Pentabio 1, Polio 2
 3 months : Pentabio 2, Polio 3
 4 months : Pentabio 3, Polio 4
 9 months : Measles
 18 months : Measles
 The patient get complete basic immunization according to age
based on guidelines from Ministry of Health 2008

9
FAMILY TREE

Child A, 3 years 6 months

10
HISTORY OF GROWTH AND DEVELOPMENT
 Growth
• Weight-for-age : - 2 SD < Z score < 0 (normoweight)
• Height-for-age : - 2 SD < Z score < 0 SD (normoheight)
• Weight-for-height : - 1 SD < Z score < 0 SD (good nutrition)
 Development
• Lie on his stomach at 3 months of age, sit at 7 months of age
• Crawling at 9 months of age, walking at 13 months of age
• Talking at 20 months of age
• Impression : Development is corresponding with his age

11
12
13
14
HISTORY OF NUTRITION
 Breastmilk plus milk formula (exclusive breastfeeding for 2 years)
 Start to eat complementary feeding in 6 months
• Packaged baby porridge, rice, vegetable, and fruit
 Before getting sick, patient eat 3 times daily
• Various food and little vegetable
• Rarely buy snacks on the roadside
 Impression : Quantity and quality of nutrition is adequate

15
GENERAL SURVEY AND VITAL SIGN
 General status
• Moderate pain, compos mentis (E4V5M6)
 Vital sign
• Heart rate : 158 times/minute, regular
• Respiration rate : 24 times/minute, regular
• Temperature : 39.30C per axilla
• SpO2 : 98% without oxygen

16
 Thorax
Head
Symmetric, retraction
Mesocephal
(-), prominent ribs (+)

Eye Cor
Pupil 2 mm/2mm, light IC not palpable, S1 and S2
reflex (+/+), conjunctiva normal, regular, murmur (-)
pallor (-/-), palpebral
edema (-/+)
Pulmo
Symmetric movement,
Ear normal fremitus, resonant
Discharge (-/-) (+/+), vesicular sound (+/+),
added sound (-/-)

Nose Abdomen
Nostril breathing Distended (-), normal
(-), discharge (-/-) turgor, bowel sound (+),
tympanic (+), ascites (-),
pain (+) epigastric regio,
Mouth liver and spleen not
Wet mucous, tonsil palpable
T1-T1, hyperemia (-)

Extremity
Neck Cold (-/- -/-), strong pulse,
Swollen lymph CRT < 2, petechie (+)
node (-)
17
BLOOD EXAMINATION
(20-02-2019/6.19AM)
 Routine blood count  Erythrocyte index
• Hb : 11.1 gram/dL  • MPV : 5.4 fl 
• Hct : 33  • PDW : 19% 
• AT : 54 thousand/ L 
• AE : 3,91 million/L 

• Eosinofil : 7 ↑
• Monosit : 12 ↑

18
PERIPHERAL BLOOD SMEAR
 Erythrocyte
• Normochromic, normocytic
 Leukocyte
• Decrease in number, blast cells (-)
 Thrombocyte
• Decrease in number, macro-thrombocytes, clumping (-)

19
CHEST X-RAY EXAMINATION
 Right Pleural Effusion with the Pleura Effusion Index 18.75%

20
PROBLEM LISTS
 History taking
 Fluctuative high fever (3 days)
 Nosebleeds and vomiting blood
 Red spot on the upper extremities
 Headache and joint pain
 Tenderness on epigastric regio

 Physical examination
• Torniquete (+)

21
PROBLEM LISTS
 Laboratory investigations
Trombocytopenia

 Radiology investigations
Pleural Effusions

22
DIAGNOSIS
 Differential diagnosis
• Dengue Fever
• Dengue Hemorrhagic Fever
 Working diagnosis
• Dengue Hemmorrhagic
Fever grade II
• Good nutrition
23
PLAN OF MANAGEMENT
• Asering infusion maintenance 70 ml/hour
• Injection of paracetamol 15 mg/kg/6 hours = 200 mg/6 hours
• Diet 1500 kkal

24
PLANNING AND MONITORING
 Planning  Monitoring
• Check complete blood count • Check vital sign per 8 h
• Routine stool examination • Check fluid balance per 8 h
• Peripheral blood smear • Check diuresis function
• Urinalysis
• RLD X-ray

25
PROGNOSIS
 Ad vitam : Dubia
 Ad sanationam : Dubia
 Ad functionam : Dubia

26
FOLLOW UP

27
28
 2. Good nutrition 2. Good nutrition

1500 1500
1500

29
2. Good nutrition

1500

30
URINE EXAMINATION (20-01-2019)
 Macroscopic
• Yellow, clear
 Urinary chemistry
• Specific gravity : 1,028
• pH : 6,0
• Leukocyte (-), erythrocyte (+)
• Protein (-), glucose (-)
• Nitrite (-), ketone (++)
• Urobilinogen (-), bilirubin (-)
 Microscopic
• Erythrocyte : 3 – 4 /HPF
• Leukocyte : 3 – 4 /HPF
• Yeast-like cell : 0
• Mucous : 0,88 /uL
• Sperm : 0
 Squamous cells : 0 – 2 /HPF
 Casts : -
31
BLOOD EXAMINATION
(20-02-2019/15.30)
 Routine blood count  Erythrocyte index
• Hb : 12.8 gram/dL • MCV : 84,6 / m
• Hct : 39% • MCH : 27,6 pg 
• AL : 8,0 thousand/ L • MCHC : 32,7 gram/dL 
• AT : 48 thousand/ L ↓ • RDW : 12,1%
• AE : 4,63 million/L ↑ • MPV : 6,7 fl 
• PDW : 20% 

32
BLOOD EXAMINATION
(20-02-2019/23.30)
 Routine blood count  Erythrocyte index
• Hb : 11.6 gram/dL • MCV : 83,8 / m
• Hct : 34% ↓ • MCH : 28,3 pg 
• AL : 9,4 thousand/ L • MCHC : 33,7 gram/dL 
• AT : 47 thousand/ L ↓ • RDW : 12,0%
• AE : 4,10 million/L • MPV : 5,7 fl 
• PDW : 19% 

33
BLOOD EXAMINATION
(21-02-2019)
 Routine blood count  Erythrocyte index
• Hb : 11.1 gram/dL ↓ • MCV : 85,5 / m
• Hct : 33% ↓ • MCH : 28,4 pg 
• AL : 10,4 thousand/ L • MCHC : 33,2 gram/dL 
• AT : 58 thousand/ L ↑ • RDW : 12,1%
• AE : 3,91 million/L • MPV : 5,4 fl 
• PDW : 19% 

34
STOOL EXAMINATION (21-02-2019)
 Macroscopic
• Consistency : Soft
• Colour : Brown
• Blood : Negative
• Mucus : Negative
• Fat : Negative
• Pus : Negative
• Undigested food : Negative
• Parasite : Negative
 Microscopic
• Epithelial cells : Negative
• Leukocytes : Negative
• Erythrocyte : Negative
• Undigested food : Negative
• Eggs and parasite : Negative
• Protozoa : Negative
• Yeast cells : Negative
• Pseudohyphae : Negative
35
LITERATURE REVIEW
36
 DEFINITION

 Dengue Haemorrhagic Fever (DHF) is a acute fever

that caused by dengue virus followed with bleeding
manifestation, or other manifestation (headache,
myalgia, athralgia), and plasma leakage.

37
ETIOLOGY

 Dengue virus
Transmitted through aedes aegypti, aedes albopictus, or
aedes polynesiensis mosquitos to the host (human)

38
39
40
41
CLASSIFICATION

42
43
44
45
WARNING SIGN

46
47
48
49
50
DHF
GRADE I-II

51
52
53
54
55
THE FOLLOWING PARAMETERS

 General condition, appetite, vomiting, bleeding

 Peripheral perfusions
 Vital signs
 Haematocrit monitoring
 Urine output

56
SIGNS OF RECOVERY

 Stable pulse, blood pressure and breathing rate

 Normal temperature
 No evidence of external or internal bleeding
 Return of appetite
 No vomiting, no abdominal pain
 Good urinary output
 Stable haematocrit at baseline level
 Convalescent confluent petechiae rash or itching, especially on the
extremities.

57
CRITERIA FOR DISCHARGING PATIENTS

 Absence of fever for at least 24 hours without the use of anti-fever

therapy
 Return of appetite
 Visible clinical improvement
 Satisfactory urine output
 No respiratory distress from pleural effusion and no ascites
 Platelet count of more than 50 000/mm3

58
HOMECARE ADVICE

 Patient needs to take adequate bed rest

 Adequate intake of fluids (no plain water) such as milk, fruit juice,
isotonic electrolyte solution, oral rehydration solution (ORS) and
barley/rice water
 Keep body temperature below 39 °C
 Tepid sponging of forehead, armpits and extremities

59
THANK YOU

60
61