Diapositiva 1

Dengue Hemorrhagic FeverBy:Astrie Hananda Febriancy090100299Duas Jourgie S.090100274

Supervisor:dr. Hj. Sri Sofyani, Sp.A(K)FACULTY OF MEDICINE UNIVERSITY OF SUMATERA UTARAHAJI ADAM MALIK GENERAL HOSPITALMEDAN2013

IntroductionAccording to WHO 2008, about 50 million dengue infections and 25,000 deaths occur worldwide annuallyThere are several factor that increased insidence of Dengue Infection which are : uncontrolled urbanization and population growth inappropriate sanitation lack of preventive programs forepidemic transmission

Literature ReviewDefenition is an acute disease caused by dengue virus which includes an arbovirs of the flavivirus family that has four different serotypes ( DEN-1, -2, -3, and -4) Transmission Human, virus and vectorPathogenesis

Clinical presentation

Diagnosis

Treatment Case ReportName :EMAge:17 YearsSex:MaleDate of Admission:September, 20th2013Main complaint:Vomiting blood

History :He has been vomitting blood since 2 days ago. Vomit is not always started with eat. History of vomitting blood (-). At emergency instalation of General Hospital Haji Adam Malik, he has puke twice. Malaise (+) since 3 days ago. Patient has lost of consciousness when he arrived. Fever (+) since 5 days ago. The fever responded to antipiretic drug. Joint pain (-), shortness of breath (-). History of drugs (-). History of bloody stool (+) since 5 days ago. Epistaxis (+). The patient has been treated at other general hospital and diagnosed with DHF grade II.

Presens statusSensorium : Apatis, Body temperature: 37,8oC, Pulse rate: 100 bpm,Respiratory Rate : 32 bpmLocalized statusHead : Light reflex (+/+), isochoric pupil, Icteric sclera (-/-), Paleness of inferior palpebral conjunctiva (-/-), Ear, nose, mouth: normal. Neck : Lymph node enlargement (-).Thorax: Symmetrical fusiformis. Epigastrial retraction (-). HR: 100 bpm, regular, murmur (-) RR: 32 bpm, regular, rhonchi (-/-)Abdomen: Soepel. Peristaltic (+) normal. Liver palpable 2 cm below arcuscosta. Lien: could not palpableExtremities: Pulse 100 bpm, regular, adequate pressure and volume, warm acral, CRT < 3

Laboratory Result

Differential Diagnosis Dengue Hemorrhagic FeverDengue FeverMalaria

Working DiagnosisDengue Hemorrhagic FeverManagementNGT 02 1-2 L/iAdrenaline tamponadeIVFD Ringer lactate 5 cc/weight(kg)1st line 46 gtt/i macro2st line 46 gtt/i macroInj. Ranitidin 50 mg/ 12hInj. Ceftriaxon 1 gr/12hSpooling NGT/8 hParacetamol 3x500 mgAntacid syr 3xC1AdviceThrombocyte transfusionFFP transfusionFull blood count/ 6hIgG, IgM anti dengue test

Follow UpSeptember 20th 21th 2013S:Vomiting blood (+) , Fever (+)O: Sensorium: Compos Mentis, T: 37,9C, BW: 55 kgHead: Light reflex (+/+), isochoric pupil, Icteric sclera (-/-), Paleness of inferior Palpebral conjunctiva (-/-), Ear : normal, nose : NGT (+) filled with blood, mouth: normal.Neck: Lymph node enlargement (-).Thorax: Symmetrical fusiformis. Epigastrial retraction (-). HR: 109 bpm, reguler, murmur (-). RR: 24 rpm, regular, rhonchi (-/-)Abdomen: Soepel. Peristaltic (+) normal. Liver palpable 2 cm below arcuscosta. Lien: not palpableExtremities: Pulse 109 bpm, regular, adequate pressure and volume, warm acral, CRT < 3

A:- Dengue Fever- DHF grade IIP:- IVFD Ringer lactate 5 cc/weight(kg)1st line 46 gtt/i macro2st line 46 gtt/i macro- Inj. Ceftriaxone 1 g/12 hour/IV - Inj. Ranitidin 50 mg/12 h / IV- Spooling NGT / 8 h- Paracetamol 3x500 mg (if NGT is clear)- Antacid syr 3x Cth II- Fasting until NGT is clear

Infection and Tropical Diseases Consult (September, 21th 2013):Conclusion : DHF grade IIAdvice therapy : D 5% Nacl 0,9 % 5cc/kgBW/hEvaluate fluid therapy/ 6 hCheck Hb, Ht and thrombocyte count / 6hMonitoring vital sign, urine output also hemorrhage16.45 pm ( 20/9/13)FFP transfusion 2 unit18.30 pm (20/9/13)Thrombocyte transfusion 250 cc (5 bag) September 22th 2013S:Vomiting blood (+) , Fever (+)O: Sensorium: Compos Mentis, T: 37,8C, BW: 55 kgHead: Light reflex (+/+), isochoric pupil, Icteric sclera (-/-), Paleness of inferior Palpebral conjunctiva (-/-), Ear : normal, nose : NGT (+) filled with blood, mouth: normal.Neck: Lymph node enlargement (-).Thorax: Symmetrical fusiformis. Epigastrial retraction (-). HR: 90 bpm, reguler, murmur (-). RR: 24 rpm, regular, rhonchi (-/-)Abdomen: Soepel. Peristaltic (+) normal. Liver palpable 2 cm below arcuscosta. Lien: not palpableExtremities: Pulse 109 bpm, regular, adequate pressure and volume, warm acral, CRT < 3

A:- DHF grade IIP:- IVFD D5% Nacl 0,9% 55 gtt/i- Inj. Ceftriaxone 1 g/12 hour/IV - Inj. Ranitidin 50 mg/12 h / IV- Spooling NGT / 8 h- Paracetamol 3x500 mg (if NGT is clear)- Antacid syr 3x Cth II- Fasting until NGT is clear

September 23th 2013S: Fever (-)O: Sensorium: Compos Mentis, T: 36,8C, BW: 55 kgHead: Light reflex (+/+), isochoric pupil, Icteric sclera (-/-), Paleness of inferior Palpebral conjunctiva (-/-), Ear : normal, nose : NGT (+) clear mouth: normal.Neck: Lymph node enlargement (-).Thorax: Symmetrical fusiformis. Epigastrial retraction (-). HR: 72 bpm, reguler, murmur (-). RR: 24 rpm, regular, rhonchi (-/-)Abdomen: Soepel. Peristaltic (+) normal. Liver not palpable. Lien: not palpableExtremities: Pulse 109 bpm, regular, adequate pressure and volume, warm acral, CRT < 3

A:- DHF grade IIP:- IVFD D5% Nacl 0,9% 28 gtt/i macro- Inj. Ceftriaxone 1 g/12 hour/IV - Inj. Ranitidin 50 mg/12 h / IV- Inj. Transamin 500 mg/8h/IV- Paracetamol 3x500 mg (if NGT is clear)- Antacid syr 3x Cth II- Cold milk diet

September 24 26th 2013S: Fever (-)O: Sensorium: Compos Mentis, T: 36,9C, BW: 55 kgHead: Light reflex (+/+), isochoric pupil, Icteric sclera (-/-), Paleness of inferior Palpebral conjunctiva (-/-), Ear : normal, nose : normal mouth: normal.Neck: Lymph node enlargement (-).Thorax: Symmetrical fusiformis. Epigastrial retraction (-). HR: 70 bpm, reguler, murmur (-). RR: 24 rpm, regular, rhonchi (-/-)Abdomen: Soepel. Peristaltic (+) normal. Liver not palpable. Lien: not palpableExtremities: Pulse 70 bpm, regular, adequate pressure and volume, warm acral, CRT < 3

A:- DHF grade IIP:- IVFD D5% Nacl 0,9% 28 gtt/i macro- Inj. Ceftriaxone 1 g/12 hour/IV - Inj. Ranitidin 50 mg/12 h / IV- Inj. Transamin 500 mg/8h/IV- Paracetamol 3x500 mg (if NGT is clear)- Antacid syr 3x Cth II- Diet M II 2000 kkal

Discussion E, 17 years old boy, was admitted to the Pediatric Department of General Hospital Haji Adam Malik on September 20th 2013 with vomitting blood as the main complaint. He has been vomitting blood since 2 days ago. Vomit is not always started with eat. History of vomitting blood (-). At emergency instalation of General Hospital Haji Adam Malik, he has puke twice. Malaise (+) since 3 days ago. Patient has lost of consciousness when he arrived. Fever (+) since 5 days ago. The fever responded to antipiretic drug. Joint pain (-), shortness of breath (-). History of drugs (-). History of bloody stool (+) since 5 days ago. Epistaxis (+). The patient has been treated at other general hospital and diagnosed with DHF grade II. Patient later was on diagnosed with Dengue Hemorrhagic Fever grade II.

DHF is a potentially fatal illness marked by high fever, hemorrhagic manifestations, and evidence of plasma leakage. In this patient, high fever and hemorrhagic manifestations was found, but the evidence of plasma leakage such as hematocrit is not increased up to 20%. Thrombocytopenia was found in this patient In the third day of hospitalization, IgG and IgM anti dengue test was done and the result shows IgM positive and IgG negative which interpretated with primary dengue. About treatment this patient is treated base on literature, adequate fluid therapy, with first management of shock by IVFD Ringer Lactate 20 cc/kgBW bolus. And continued by D5% NaCl 0,9% 5cc/kgBW/hour when patient is already stable.

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