Case CHAPTER II Dengue Haemorrhagic Fever grade II + Varicella

7/27/2019 Case CHAPTER II Dengue Haemorrhagic Fever grade II + Varicella

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CHAPTER II

CASE REPORT

II.1. IDENTIFICATION

Name : Mr. A MSex : Male

Age : 16 Years Old

Address : Jl. Robani Kadir Lr. Nurul Huda Kelurahan Talang Putri, P laju,

Palembang

Status : Single

Occupation : Student

Religion : Moslem

Admitted to hospital : Desember 9 th 2008

II.2. ANAMNESIS (Autoanamnesis)

Chief of complain

Nasal bleeding since 1 day before admitted to hospital

History of illness

6 days before admission, patient complained of having fever, intermitten, shaking chills

sometimes (+), headache (+), retrorbital pain (-), fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain

(-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination.

Patient wasnt going anywhere to take medication for these complaints.

3 days before admission, fever decreased, headache (+), retrorbital pain (-), fatigue (+), joint

and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (-), stomach pain (-), decrease of

appetite (+), cough (-), cold (-),there was no disorder in defecation and urination, patient

complained about rash spread on the chest and trunk, rash was itchy. Patient use baby powder todecrease the itchy.

1 day before admission, the fever increased, intermitten, shaking chills sometimes (+),

headache (+), retrorbital pain (-), fatigue (+), joint and skletal pain (+), nose bleeding (+), gum

bleeding (+), nausea (+), vomiting (+), the vomit contained with wreckage of food, stomach pain


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(-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation and urination.

Patient complained about rash spread to hand and face, itchy (+), patient went to the

Muhammadiyah Hospital but, he was reconciled to the Mohammad Hoesin Hospital.

History of past illness

History of Malaria fever was denied

History of Thypoid fever was denied

History of Dengue fever was denied

History of going to endemic area was denied

History of family disease

History of chicken pox disease on his neighbour.

II.3 PHYSICAL EXAMINATION

o General examination

General condition : sick

Sickness condition : moderate sickness

Consciousness : compos mentis

Blood pressure : 110/70 mmHg

Pulse rate : 80 times/minute, regular

Respiration rate : 20 times/minute

Temperature : 37,3 0 C

Dehydration : (-)

Weight : 48 kg

Height : 162 cm

Nutrition : RBW = 86%

Impressive: Underweight

o Spesific examination

1. Skin


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Skin color is puce

Normal pigmentation

Efloresence, black spot on some places.

Scar (-)

Hyperhidrosis (-)

Normal hair growth

Good turgor

Wet or dry in palpitation (-)

Nodul subcutan (-)

2. Lymph gland

There were no enlargement of the lymph nodes on submandibular, neck, axillaries and

inguinal.

3. Head

Oval, symmetrical

Puffy face (-)

Deformity (-)

Malar rash (-) Alopecia (-)

4. Eye

Eksophtalmus and enophtalmus (-)

Edematous palpebra superior (-)

Pale of conjunctiva palpebra (-)

Sclera icteric (-)

5. Nose

Epistaxis (+)

Normal nasal septum and mucous layer


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6. Ear

Good hearing

Normal both of meatus accusticus externus

7. Mouth

Typhoid tongue (-)

Rhagaden of lips (-)

Stomatitis (-)

Papil atrophy (-)

Gum bleeding (+) Fetor oris (-)

8. Neck

Thyroid gland not palpable, thyroid bruit (-)

Jugular vein pressure (5-2) cmH 20

Hypertrophy of musculus sternocleidomastoideus (-), stiffness (-)

9. Thorax

Normal shape

Extended intercostal section (-)

Retraction (-)

Venectasis (-)

Spider naevi (-)

10. Lung Inspection : symetrical of static and dynamic right and left are equal

Palpation : stemfremitus right and left are equal

Percussion : sonor both of the lung

Auscultation : Vesiculer (+) N, Ronchi (-), Wheezing (-)


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11. Cor

Inspection : ictus cordis not seen

Palpation : ictus cordis not palpable

Percussion : upper boundary of cor is ICS III, left boundary of cor is linea mid

clavicula sinistra, right boundary of cor is linea sternalis dextra

Auscultation : HR (80 x/m), Murmur (-), Gallop (-)

12. Abdomen

Inspection : flat, venectation (-),

Palpation : Pain (-) , liver and lien are unpalpable

Percussion : tympany, shifting dullness (-) Auscultation : bowel sound (+) normal

13. External genitalia :

not examined

14. Upper extremity

Pain on joint (+)

Pale on finger (-)

Erythema of palm (-)

Rumplee leed (-)

Pitting edema (-)

Clubbing finger (-)

Tremor (-)

Normal physiological reflex

15. Lower extremity

Varices (-)

edema (-)

Pain on joint (+)


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Third examination (15.00 am)

o Hemoglobin : 10 g/dl ( N: 14-18 g/dl )

o Hematocrite : 30 vol% ( N: 40-48 vol% )

o Trombocyte : 22.000/mm 3 ( N: 200000-500000/ mm )

Fourth examination (21.00 pm)

o Hemoglobin : 9,6 g/dl ( N: 14-18 g/dl )



Urine Analysis

o Epithelial cell : (+)

o WBC : 2-3/LPB ( N: 0-5/LPB )

o RBC : 0-1/LPB ( N: 0-1/LPB )

o Cylinder : (-) ( N: - )

o Crystal : (-) ( N: - )

o Protein : (-) ( N: - )

o Glucose : (-) ( N: - )

o Nitrit : (-) ( N: - )

Laboratory Findings (Desember 11 th 2008)

First examination (03.00pm)

Blood analysis




Second examination (09.00 pm)





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o PT : 14,3

o APTT : 33,3

Urine Analysis

o Epithelial cell : (+)

o WBC : 3-4/LPB ( N: 0-5/LPB )

o RBC : 100/LPB ( N: 0-1/LPB )

o Cylinder : (-) ( N: - )

o Crystal : (-) ( N: - )

o Protein : (+) ( N: - )

o Glucose : (-) ( N: - )

o Darah/Hb : (+) ( N: - )

o Nitrit : (-) ( N: - )

Laboratory Findings (Desember 12 th 2008)

First examination (03.00pm)

Blood analysis




Second examination (09.00 pm)









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II. RESUME

A man initialed name Mr. AM, 16 years old, admitted to hospital in November 9 th 2008,

with rash in whole of body since 1 day before admitted to hospital

6 days before admission, patient complained of having fever, intermitten, shaking chills

sometimes (+), headache (+), joint paint (-), retrorbital pain (-), fatigue (+), joint and skletal pain

(+), sign of bleeding (-), nausea (+), vomiting (+), the vomit contained with wreckage of food,

stomach pain (-), decrease of appetite (+), cough (-), cold (-), there was no disorder in defecation

and urination. Patient wasnt going anywhere to take medication for these complaints.

3 days before admission, fever decreased, headache (+), joint paint (-), retrorbital pain (-),

fatigue (+), joint and skletal pain (+), sign of bleeding (-), nausea (+), vomiting (-), stomach pain

(-), decrease of appetite (+), cough (-), cold (-),there was no disorder in defecation and urination,

patient complained about rash spread on the chest and trunk, rash was itchy. Patient use baby

powder to decrease the itchy.

1 day before admission, the fever increased, intermitten, shaking chills sometimes (+),

headache (+), joint paint (-), retrorbital pain (-), fatigue (+), joint and skletal pain (+), nose

bleeding (+), gum bleeding (+), nausea (+), vomiting (+), the vomit contained with wreckage of

food, stomach pain (-), decrease of appetite (+), cough (-), cold (-), there was no disorder in

defecation and urination. Patient complained about rash spread to hand and face, itchy (+), finally

patient went to RSMH for medication.

The neighbour of the patient has history chicken pox disease.

From physical examination, the general condition of the patient was moderate sickness and

his consciousness was compos mentis. Blood pressure 110/70 mmHg, pulse rate 80

times/minute, reguler, respiration rate 20 times/minute, temperature 37,3 0C, RBW (weight

= 48 kg and height = 162 cm) = 86%, impressive underweight, jugular vein pressure (5-2)

cmH2O. Normal thorax, While abdomen examination, pain on epigastrium (-), liver and

spleen is unpalpable, and skin, there was Efloresence, black spots on some places.


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II.6 WORKING DIAGNOSIS

Dengue Haemorrhagic Fever grade II + Varicella

II.7 DIFFERENTIAL DIAGNOSISo Typhoid fever

o Viral acute infection

II.8 TREATMENT

Nonpharmachology

Bed rest

Diet BB

Pharmachology

IVFD Rl gtt XL/menit

Cefotaxim 2x1 gr

Domperidon 3x1 tab

Salicyl talc

Vit. B1, B6, B12 3x1 tab

Paracetamol 500 mg (prorenata)

II.9 PLANNING

Routine Blood analysis

Hb, Ht, trombocyte every six hours


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II.10 PROGNOSIS

Quo ad vitam : Bonam

Quo ad functionam : Bonam


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II.11 FOLLOW UP

December 10 th 2008

S complaint : headache (+), nose bleeding (+), gum bleeding (+)

O

Sense Compos mentisBlood pressure 110/70 mmHg Pulse rate 80 x/menit

Temperature 36.5 C Respiration rate 20 x/menit

Head Pale of conjunctiva palpebra (-), icteric sclera (-)

Neck JVP = (5-2) cmH 20, Lymph gland enlargement (- )

Cor HR = 80 x/min, regular, murmur (-), gallop (-)

Pulmo vesicular (+) N,Ronchi (-), wheezing (-)

Abdomen Flat, pain (-) on epigastrium, liver and spleen are unpalpable,

bowel sound (+) normal

Extremitas Edema (-)

A DHF grade II + varicella

P Nonpharmachology

Bed rest

Diet BB

Pharmachology


Cefotaxim 2x1 gr

Domperidon 3x1 tab

Salicyl talc




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December 12 th 2008

S complaint : nose bleeding (+), gum bleeding (+), hematuria (+)

O

Sense Compos mentis

Blood pressure 110/70 mmHg Pulse rate 80 x/menit

Temperature 36,5 C Respiration rate 18 x/menit

head Pale of conjunctiva palpebra (-), icteric sclera (-)

neck JVP = (5-2) cmH 20, Lymph gland enlargement (-)







P Nonpharmachology

Bed rest

Diet BB

Pharmachology


Cefotaxim 2x1 gr

Domperidon 3x1 tab

Salicyl talc


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December 13 th 2008

S complaint : (-)

O

Sense Compos mentis

Blood pressure 120/80 mmHg Pulse rate 78 x/menit

Temperature 36,5 C Respiration rate 22 x/menit

head Pale of conjunctiva palpebra (-), icteric sclera (-)

neck JVP = (5-2) cmH 20, Lymph gland enlargement (- )







P Nonpharmachology

Bed rest

Diet BB

Pharmachology


Cefotaxim 2x1 gr

Domperidon 3x1 tab

Salicyl talc


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Repeat DDR analysis

Case CHAPTER II Dengue Haemorrhagic Fever grade II + Varicella

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