DENGUE HEMORRHAGIC FEVER

Oleh: Nucky Vera Arnaz, S.Ked Rilahi Zahrah Harahap, S.Ked

Pembimbing: Prof.Dr.Zarkasih Anwar Sp.A(K)

Case Report

IDENTIFICATION a. Name b. Age c. Sex d. Nationality e. Religion f. Address g. Admitted to hospital

: : : : : : :

AI 14 y.o Male Indonesia Moslem Palembang October, 28th 2011

ANAMNESIS

Chief complain

: Cool in feet and hands

Additional complain : red spots in feet and hands

HISTORY

OF

ILLNESS

 5 days before admission

- High fever of unknown origin, intermitten -Headache -Muscle pain -Epigastric pain -Increased frecuent of urination, yellowish colour - Took medication but his complain didnt decreased.

2 days before admission

-Still cold Red spots in extremities (feet and hands)

 6 hours before admission

-weak and cool in extremities Went to Bari Hospital, took IV line (RL 2 kolf), reconciled to the Mohammad Hoesin Hospital

-History of past illness : History of DHF in July 2011 -History of family disease: History of DHF on his family or neighbour was denied

History of pregnancy, growth and development, feeding, immunitation

unknown

Physical Examination
General Examination General condition Consciousness Weight Height Nutrition Blood Pressure Pulse Rate Suhu Respiration rate (Oktober, 31st 2011) : sick : Compos mentis : 44 kg : 145 cm : normoweight : 110/70 mmHg : 78 x/minute : 36, 1C : 26 x/menit

Specific examination Skin :Petechiae Head : Abnormality (-) Neck : Thyroid gland not palpable, thyroid bruit (-) Jugular vein pressure (5-2) cmH20 Thorax Cor and lung : abnormality (-) Extremities : cool extremities (+)

Neurological Examination
Motoric function : Normal range Sensoric function : Normal range Craniales nervus : Normal

Additional Examination

Laboratory finding (28 Oktober 2011) First examination Blood analysis: Hb : 16,4 g/dl Ht : 47 vol % Leukosit : 3500/mm3 Trombosit : 36.000/mm3 Diff.count : 0/7/1/46/40/6

Urine Analysis: Sel epitel : Leukosit : Eritrosit : Silinder : Kristal : Protein : Glukosa :

(+) 2-3/LPB 0-1/LPB (-) (-) (-) (-)

Hb = 16,4 15,8 15,5 15,9 Ht = 47% 45%46%40% Trombosit = 36000 1700022000134000 IgG (+) dan IgM (+)

DIAGNOSIS BANDING

DHF Grade III Thypoid fever

Working diagnose

DHF grade III

TERAPI

MRS IVFD RL 10cc/KgBB/jam (440 cc/ jam) Balance cairan per 6 jam Banyak minum Kurva suhu dan observasi tanda vital per 15 menit Rencana pemeriksaan lab : Hb, Ht, Trombosit, IgG dan IgM anti dengue

PROGNOSIS

Quo ad vitam Quo ad functionam

: Dubia ad Bonam : Dubia ad Bonam