Fever et causa Viral Infection susp.

Exanthema Subitum

By :
Muhammad Faiz Insanul Khalis, MD

Supervisor :
M. Diana Rahim, MD

Indonesian Doctor Internship Program

Guntur Hospital Garut
October 2021
PATIENT IDENTITY
Name : An AH
Age : 15 years old
Gender : Male
Medical Record Number: 171660
Admission Date : October 6 2021
Time : 18.00
GP : dr. Martinus
HISTORY TAKING
• Chief complain: Fever and reddish spot

The patient came brought by the family with complaints of fever since 3
days before admitted to the Guntur Hospital. The fever was felt to up and
down. Diarrhea 3x/day, mucus (+), blood (+), nausea (+), vomiting (-).
After the 3rd day of fever, reddish spots appeared on the skin itchy and
hot. The family has tried to treat it with drugs but it hasn't improved.
History of nosebleeds (-), allergies (-), asthma (-), bleeding gums (-),
coughing for a long time (-), seizures (-), night sweats (-), shortness of
breath(-), muscle pain (-), and other disease (-). History of covid
vaccination 2 times.
PHYSICAL EXAMINATION
General Condition : Alert
Awareness : Composmentis
GCS : 15
Blood Pressure : 100/70 mmHg
Pulse Rate : 100x/minute
Respiratory Rate : 20x/minute
Temperature : 36,7 C
Oxygen Saturation : 98% free air

Weight : 70 kg
Height : 169 cm
BMI : 24.5
PHYSICAL EXAMINATION
Head : mesoochepal
Eyes : Anemic Conjungtiva -/-, Icteric Sclera - / -
Nose : nostring breathing ( - )
Mouth : cyanosis ( - )
Neck : lymph node enlargment ( - )
PHYSICAL EXAMINATION
Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : Vesicular breath sounds, crackle - / -, wheezing - / -
Abdomen : flat, soepel, bowel sound ( + ) normal, tenderness in
epigastric and suprapubic
Liver : within normal limits
Spleen : within normal limits
Extremities :
Warm, Edema ( - ), CRT < 2 second

Skin:
Normal turgor, borderless erythema upper and lower extremities
and abdomen
SUPPORTING EXAMINATION
• LABORATORY EXAMINATION RESULT (06-10-2021)
– Blood Routine:

• Hemoglobin : 14.5 gr %

• Leucocyte : 11200 /mm2

• Hematocrite : 47.6 %
• Thrombocyte : 212.000/mm3

– Immunology :

• Rapid antigen Covid-19 : Negative

DIAGNOSE
Fever et causa Viral Infection susp. Exanthema
Subitum
MANAGEMENT
• IVFD Asering 20 tpm
• Inj. Omeprazole 1x40 mg IV
• Inj Ondansentron 2x1 amp IV
• PO Molagit 3x2 tab
• PO L-bio 2x1 sch