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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 )
o Hematocrite : 28 vol% ( N: 40-48 vol% )
o Trombocyte : 30.000/mm 3 ( N: 200000-500000/ mm )
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
o Hemoglobin : 12,7 g/dl ( N: 14-18 g/dl )
o Hematocrite : 36 vol% ( N: 40-48 vol% )
o Trombocyte : 34.000/mm 3 ( N: 200000-500000/ mm )
Second examination (09.00 pm)
o Hemoglobin : 11,6 g/dl ( N: 14-18 g/dl )
o Hematocrite : 34 vol% ( N: 40-48 vol% )
o Trombocyte : 25.000/mm 3 ( N: 200000-500000/ mm )
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Third examination (15.00 am)
o Hemoglobin : 10,6 g/dl ( N: 14-18 g/dl )
o Hematocrite : 30 vol% ( N: 40-48 vol% )
o Trombocyte : 33.000/mm 3 ( N: 200000-500000/ mm )
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
o Hemoglobin : 10,5 g/dl ( N: 14-18 g/dl )
o Hematocrite : 30 vol% ( N: 40-48 vol% )
o Trombocyte : 14.000/mm 3 ( N: 200000-500000/ mm )
Second examination (09.00 pm)
o Hemoglobin : 10,5 g/dl ( N: 14-18 g/dl )
o Hematocrite : 31 vol% ( N: 40-48 vol% )
o Trombocyte : 42.000/mm 3 ( N: 200000-500000/ mm )
Third examination (21.00 am)
o Hemoglobin : 10,1 g/dl ( N: 14-18 g/dl )
o Hematocrite : 31 vol% ( N: 40-48 vol% )
o Trombocyte : 32.000/mm 3 ( N: 200000-500000/ mm )
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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
IVFD Rl gtt XL/menit
Cefotaxim 2x1 gr
Domperidon 3x1 tab
Salicyl talc
Vit. B1, B6, B12 3x1 tab
Paracetamol 500 mg (prorenata)
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Vit. B1, B6, B12 3x1 tab
Paracetamol 500 mg (prorenata)
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 (-)
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
IVFD Rl gtt XL/menit
Cefotaxim 2x1 gr
Domperidon 3x1 tab
Salicyl talc
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Vit. B1, B6, B12 3x1 tab
Paracetamol 500 mg (prorenata)
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 (- )
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
IVFD Rl gtt XL/menit
Cefotaxim 2x1 gr
Domperidon 3x1 tab
Salicyl talc
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Vit. B1, B6, B12 3x1 tab
Paracetamol 500 mg (prorenata)
Repeat DDR analysis