AFTERNOON

REPORT
June 3rd 2021
Case from June 2nd 2021
01 PATIENT IDENTITY

CONTENTS
TABLE OF
02 ANAMNESIS

03 PHYSICAL EXAMINATION

DIAGNOSTIC
04 EXAMINATION

05 MANAGEMENT

06 MONITORING

07 PROGNOSIS
PATIENT IDENTITY

Name : IKS
Medical Record : 21021934
Age : 27
Sex : Male
Religion : Hindu
Marital Status : Married
Address : Jalan Graha Wisata, Sidakarya
Occupation : Security Guard
ANAMNESIS
Chief complaint : Fever

Companion complaint : Myalgia, nausea and vomiting, retro orbital pain, headache

Present medical history : The patient came to the ER Sanglah Hospital on Saturday May 29, 2021 at 13:54 WITA
with the chief complaint of fever. The fever has been felt since 7 days ago (Wednesday, 26 May 2021) in the
morning. The fever was suddenly high up to 390C. The fever worsen at night until the patient couldn’t sleep. But the
fever has been decreased while patient taking paracetamol, obtained from the clinic on Wednesday afternoon.
However, the fever recurred on Thursday 27 May, so the patient went to the puskesmas for treatment. Puskesmas
gave him paracetamol and the fever relieved, but the fever appeared again when he stopped taking the paracetamol.
The fever pattern was intermittent until he came to the ER Sanglah (3 days of fever).

Patient also complained of nausea and vomiting on May 26-27 (fever day 1-2). 1-2 times a day after each meal. The
vomits filled with saliva and food without blood with approximately 200 ml. The complaint of nausea and vomiting
was getting better when patient taking domperidone syrup from the puskesmas. Patient came to ER Sanglah without
any complaint of nausea and vomiting.
ANAMNESIS
Patient also complained of pain in all parts of the head like a stabbing since the first day of fever until difficulty
sleeping. Complaints feel better when the fever goes down. NRS 9/10 until the patient grimaced. Patient also
complained of retroorbital pain especially when moving the eyeballs since the first day of fever. The patient
complained of aches all over the body, especially from the knees to the bottom since the first fever and
improved when the fever went down. The patient said that there were red spots on the shoulder area since
Saturday, but when the examination was carried out there were none. Complaints of cough, runny nose,
shortness of breath and spontaneous bleeding were denied. BAB and BAK within normal limits with a urine
volume of approximately 4 liters.
ANAMNESIS
Past medical history : Patient said he never had a history of dengue fever before. History of diseases such as
diabetes, hypertension, asthma and heart disease was denied

Medication history : Paracetamol 500 mg, Domperidone 60 ml, Vitamin B6 15 mg

Family history : There was no family member who has the same complaints. History of diseases such as
diabetes, hypertension, asthma and heart disease was denied

Social history : The patient has a history of smoking and drinking alcohol but this is rarely done. The patient
lives in Sidakarya and the patient's home area is close to the river. The patient's workplace in the Benoa area is
also close to the swamp area. The patient had no history of traveling outside the area. The patient also has no
history of contact with Covid-19 patients
PHYSICAL EXAMINATION
Present Status
● General appearance: Mildly ill
● Consciousness : Compos Mentis
● GCS : E4V5M6
● Blood pressure : 120/80 mmHg
● Pulse rate content : 80x/min, regular, adequate
● Respiration rate : 19x/min, regular
● Temperature axilla : 36,3°C
● SpO2 : 100% room air
● Height : 165cm
● Weight : 80Kg
● BMI : 29,3Kg/m2
 PHYSICAL EXAMINATION
General Status

● Eye : Anemic Conjunctiva (-/-), icteric sclera (-/-), pupil isochor, palpebral
edema (-)
● ENT
Ear : Discharge (-/-)
Nose : Discharge (-/-)
Throat : pharyngeal hyperemic (-)
● Mouth : cyanosis (-), oral ulcus (-)
● Tongue : normal
● Neck : JVP 5+2 cm H20, lymph node enlargement (-), thyroid gland
enlargement (-)
PHYSICAL EXAMINATION
● Chest : General Status
● Cor
Inspection : ictus cordis unseen
Palpation : ictus cordis unpalpable
Percussion : right border ICS 4 PSLD, left border ICS 4 MCLS
Auscultation : S1 S2 single reguler, murmur (-)
● Pulmo
Inspection : symetric in static and dynamic
Palpation : symetric, VF normal symetric
Percussion : Sonor | Sonor
Sonor | Sonor
Sonor | Sonor

Auscultation : Vesikuler Ronchi Wheezing

+ | + - | - - | -
+ | + - | - - | -
+ | + - | - - | -
 PHYSICAL EXAMINATION
General Status
● Abdomen
Inspection : Distention (-)
Auscultation : Peristaltic (+) normal
Palpation : Hepatomegaly (-), splenomegaly (-), abdominal pain (-),
renal unpalpable
Percussion : Tympanic (+), Ascites (-), Shifting dullness (-),
undulation (-), liver span 7 cm
● Extremity : warm , edema CRT < 2 s
+| + - |-
+|+ - |-

Artery dorsalis pedis palpable, adequate content

DIAGNOSTIC EXAMINATION
Lab Exam (May, 28th 2021)
CBC Value Ref Range
WBC 3.96 3.80 - 10.60 CBC Value Ref Range
Ne% 76.0 40.0 -75.0 % MCH 28.8 26.0-34.0
Ly% 13.9 20.0 - 45.0% MCHC 35.7 32-36
Mo% 10.1 2,0-10,0% RDW 11.8 11.50-14.50
Eo% 0.00 1.0-6.0% PLT 102 150-440
Ba% 0.00 0.0-1.0% MPV 14.1 6.30-11.10
Ne# 3.01 2.0-7.50 PCT 0.140 0.150-0.400
Ly# 0.55 1.50-4.00
Mo# 0.40 0.20-0.80
Eo# 0.00 0.00-0.40
Ba# 0.01 0.0-0.1
RBC 5.49 4.40-5.90
HGB 15.80 13.2-17.3
HCT 44.20 40.0-52.0
MCV 80.5.70 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (May, 29th 2021)
CBC Value Ref Range CBC Value Ref Range
WBC 3.45 4.1-11.0 MCH 28.70 26.0-34.0
Ne% 63.10 47-80 % MCHC 36.40 31-36
Ly% 24.10 13-40% RDW 11.40 11.60-14.80
Mo% 12.50 2,0-11,0% PLT 53.00 150-440
Eo% 0.00 0.00-5.0% MPV 14.00 6.80-10.00
Ba% 0.30 0.0-2.0% NLR 2.62 ≤3.13
Ne# 2.18 2.5-7.5
Ly# 0.83 1.00-4.00 Chemistry Value Ref range
Mo# 0.43 0.1-1.2 AST/SGOT 97.5 5-34 U/L
Eo# 0.00 0.00-0.50 ALT/SGPT 46.60 11.00-50.00 U/L
Ba# 0.01 0.0-0.1 BUN 10.30 8.0-23.0 mg/dL
RBC 6.00 4.5-5.9
Creatinin 0.90 0.70-1.25mg/dL
HGB 17.20 13.5-17.5
Dengue NS-1
HCT 47.20 41.0-53.0 Positive Negative
Antigen
MCV 78.70 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (May, 30th 2021)
CBC Value Ref Range
WBC 4.53 4.1-11.0 CBC Value Ref Range
Ne% 61.80 47-80 % MCH 28.40 26.0-34.0
Ly% 26.50 13-40% MCHC 35.90 31-36
Mo% 11.50 2,0-11,0% RDW 11.40 11.60-14.80
Eo% 0.00 0.00-5.0% PLT 41.00 150-440
Ba% 0.20 0.0-2.0% MPV 13.40 6.80-10.00
Ne# 2.80 2.5-7.5 NLR 2.33 ≤3.13
Ly# 1.20 1.00-4.00
Mo# 0.52 0.1-1.2
Eo# 0.00 0.00-0.50
Ba# 0.01 0.0-0.1
RBC 5.71 4.5-5.9
HGB 16.20 13.5-17.5
HCT 45.10 41.0-53.0
MCV 79.00 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (May, 31st 2021)
CBC Value Ref Range
CBC Value Ref Range
WBC 5.15 4.1-11.0
MCH 28.00 26.0-34.0
Ne% 54.20 47-80 %
MCHC 35.50 31-36
Ly% 28.50 13-40%
RDW i 11.60-14.80
Mo% 15.50 2,0-11,0%
PLT 39.00 150-440
Eo% 1.40 0.00-5.0%
NLR 1.90 ≤3.13
Ba% 0.40 0.0-2.0%
Ne# 2.79 2.5-7.5
Ly# 1.47 1.00-4.00
Mo# 0.80 0.1-1.2
Eo# 0.07 0.00-0.50
Ba# 0.02 0.0-0.1
RBC 5.35 4.5-5.9
HGB 15.00 13.5-17.5
HCT 42.20 41.0-53.0
MCV 78.90 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (June, 1st 2021)
CBC Value Ref Range CBC Value Ref Range
WBC 5.29 4.1-11.0 MCH 28.50 26.0-34.0
Ne% 44.30 47-80 % MCHC 35.80 31-36
Ly% 39.10 13-40% RDW 11.50 11.60-14.80
Mo% 13.20 2,0-11,0% PLT 33.00 150-440
Eo% 2.60 0.00-5.0% MPV 12.30 6.80-10.00
Ba% 0.80 0.0-2.0% NLR 1.13 ≤3.13
Ne# 2.34 2.5-7.5
Ly# 2.07 1.00-4.00 Chemistry Value Ref range
Mo# 0.70 0.1-1.2
AST/SGOT 99.4 5-34 U/L
Eo# 0.14 0.00-0.50
ALT/SGPT 47.50 11.00-50.00 U/L
Ba# 0.04 0.0-0.1
RBC 5.08 4.5-5.9
HGB 14.50 13.5-17.5
HCT 40.50 41.0-53.0
MCV 79.70 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (June, 2nd 2021)
CBC Value Ref Range CBC Value Ref Range
WBC 6.57 4.1-11.0 MCH 28.30 26.0-34.0
Ne% 34.80 47-80 % MCHC 35.70 31-36
Ly% 49.00 13-40% RDW 11.70 11.60-14.80
Mo% 12.60 2,0-11,0% PLT 75.00 150-440
Eo% 2.70 0.00-5.0% MPV 13.10 6.80-10.00
Ba% 0.90 0.0-2.0% NLR 0.71 ≤3.13
Ne# 2.28 2.5-7.5
Ly# 3.22 1.00-4.00 Serology Value Ref range
Mo# 0.83 0.1-1.2 Anti DHF
Positive Negative
Eo# 0.18 0.00-0.50 IgM
Ba# 0.06 0.0-0.1 Anti DHF
Positive Negative
RBC 5.05 4.5-5.9 IgG

HGB 14.30 13.5-17.5

HCT 40.10 41.0-53.0
MCV 79.40 80.0-100.0
DIAGNOSTIC EXAMINATION
Lab Exam (WBC, HGB, PLT, HCT)

Parameter 28/05/ 29/05/ 30/05/ 31/05/ 01/06/ 02/06/ Ref Range

2021 2021 2021 2021 2021 2021

WBC 3.96 3.45 4.53 5.15 5.29 6.57 4.10 - 11.10

HGB 15.80 17.20 16.20 15.00 14.50 14.30 13.5 -17.5

HCT 44.20 47.20 45.10 42.20 40.50 40.10 41.0-53.0

PLT 102 53.0 41.0 39.0 33.0 75.0 150 - 440

DIAGNOSTIC EXAMINATION
Xray thorax AP, May 29th 2021

Soft tissue: tak tampak kelainan

Tulang-tulang : tidak tampak kelainan
Diaphragma kanan kiri normal
Sinus pleura kanan kiri tajam
Cor : besar dan bentuk kesan normal,
CTR 57%
Trachea : letak di tengah, airway
patent
Pulmo : tak tampak konsolidasi/nodul.
Corakan bronchovaskuler normal
Kesan:
Cor dan pulmo tak tampak kelainan
ASSESSMENT

1. Dengue Fever without warning sign (Day 7)

2. Transaminitis ec Dengue related
MANAGEMENT

- IVFD RL 30 tpm
- Paracetamol 500 mg every 8 hours PO
- KIE Fluid intake 1 - 1,5L/day
- Total bed rest
MONITORING

- General condition
- Vital sign
- Fluid Balance
- Complete blood count every 24 hour
- SGOT/SGPT
PROGNOSIS

● Ad vitam : dubia ad bonam

● Ad functionam : dubia ad bonam
● Ad sanationam : dubia ad bonam
THANK YOU