By : Erina Puspitasari Priyatna

CASE REPORT 1 Supervisor :

DHF M Diana Rahim, MD
PATIENT IDENTITY
Name : Mr.G
Age : 33 years old
Gender : Male
No. RM : 114839
Admission Date : March, 16th 2021
Address : Perum Pamoyanan Blok K no 16 Kab.Garut
COURSE OF DISEASE
14/03/2021 15/03/2021 16/03/2021

Fever Fever Fever

↓ ↓
Were given Referred to
antipyretic Emergency Department
By self Unit with CC:
Fever,nausea,fatigue,
Arthtralgia, epigastric
pain
HISTORY TAKING
Chief complain : Fever
The patient came to the emergency unit at Guntur Hospital with complaint of fever
since 2 days before admission. Initially the fever was fluctuate, at this time the
fever was felt continuously. The patient also feels weakness and soreness all over
the body. Nausea (+), Fatigue (+), epigastric pain (+), Vomiting (-), heartburn (-),
diarrhea (-), constipation (-). The reddish spots on the extremities and epistaxis were
denied by the patient.
Symptoms of cough, runny nose, shortness of breath, history of going out of town
and contact history with confirmed covid were denied by the patient. Before the
patient goes to the ER, he has treated at the public health center but thrombocite
decrease around 66.000/mm3.
COURSE OF DISEASE
EMERGENCY DEPARTMENT
UNIT

O : BP:120/80mmHg, N: 58x/m, RR: 20x/m, T:36,7 LABORATORY EXAMINATION

Abdomen : soepel (+), tenderness (-), epigastruim pain (+) • Hb : 19.3 g/dl
A : Dengue Hemorrhagic Fever gr I • Leukocyte : 9800/ul
P: • Thrombocyte : 66000/ul
IVFD RL 20 dpm Laboratory chech/24jam • HCT : 55%
Omeprazole 1x40mg IV • IgG dengue : (+)
Dexametsone 3x1 amp IV • IgM dengue : (+)
Cefotaxime 2x1gr IV • NS-1 : (-)
Dehaf 3x1 sach PO
Sucralfat 3x2cth PO
Becom-c 1x1 PO
Paracetamol 3x500mg PO
DIAGNOSTIC
Dengue Hemorrhagic Fever gr I
 FOLLOW UP
March, 17th 2021 March, 18th 2021

S: Fever(+), arthtralgia, severe epigastric pain

(+), nausea (+) S: Fever (-), arthtralgia, epigastric pain (+)

O: BP: 110/70 mmHg, PR: 82 bpm, RR: 20 O: BP: 120/80 mmHg, PR: 80 bpm, RR: 20
bpm, S: 36,1 OC, epigastric tenderness (+) bpm, S: 36,2 OC, epigastric tenderness (+)
A: DHF grade I
A: DHF grade I
P: IVFD RL 20 tpm, Omeprazole 1 x 40 mg IV,
P:IVFD RL 20 tpm, cefotaxime and Paracetamol 500mg 3x1 PO, Dehaf 3x1 sach
dexametasone stop, Omeprazole 1 x 40 mg PO, Sucralfat 3x2cth PO, Becom-c 1x1 PO
IV, Paracetamol 500mg 3x1 PO, Dehaf
3x1 sach PO, Sucralfat 3x2cth PO, Becom-
c 1x1 PO Hb: 16,8 ; L: 11.300; Tr: 69.000; Hct: 49.5
Swab Antigen : Negative (move to non-
isolation ward
Hb: 19 ; L: 2.000; Tr: 65.000; Hct: 50.2
 FOLLOW UP
March, 19th 2021

S: Fever(-), epigastric pain (-)

O: BP: 120/80 mmHg, PR: 66 bpm, RR: 20 bpm, S:
36,3 OC
A: DHF grade I
P: IVFD RL 20 tpm, Omeprazole 1 x 40 mg IV,
Paracetamol 500mg 3x1 PO, Dehaf 3x1 sach PO,
Sucralfat 3x2cth PO, Becom-c 1x1 PO

Hb: 16,7 ; L: 9000; Tr: 108.000; Hct: 49.4

 Improvement thrombocite (BLPL)
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY