DUTY REPORTEMERGENCY ROOM3RD FEBRUARY 2016 SEVERAL APPROACH TO PROBABLE DENGUEGP on duty: dr. Husna & dr. FitriaCo-ass on duty:Evan & FauzanSupervisor : dr Soroy Lardo SppD FINASIMDivision Tropical Medicine and Infectious DiseasesIndonesia Army Central Hospital Gatot Soebroto

RECAPITULATION

1. Mr. F / 53 yo / Vomitus observation

2. Mr. A / 49 yo / Dyspneu observation, CAD

3. Mrs. I / 71 yo / low intake geriatri

4. Mr. S / 65 yo / DM type II, CAD

5. Mr. I / 46 yo / Viral infection

6. Mr. J / 43 yo / vomitus post brachytheraphy

7. Mr. E / 24 yo / tonsilofaringitis akut viral

8. Ms. I / 21 yo / febris observation day 1

PATIENT’S IDENTITY Name: I Sex : Female MR no : 40-96-xx Age : 21 y.o Address : Gunung Sahari Raya, Central Jakarta Occupation : Student Religion : Islam Marital status : Single

ANAMNESIS Autoanamnesis Chief complaint:

Fever for 20 hours before admission Additional complaints:

Nausea and vomiting Headache

HISTORY OF PRESENT ILLNESS

Fever for 20 hours before admission Sudden onset of high fever Temperature was not recorded but subsides with

paracetamol 4-5 hours after medication temperature rise Nausea (+) especially when patient tried to eat Vomit 1 time before admission, containing food, no blood Headache (+) Muscle and joint pain (+)

No abdominal pain No pain/burning sensation, normal urine color and

frequency Defecation no change in consistency,

frequency, and color Thirst (+) No other person around experienced similar

symptoms

History of other systemic illnesses: Hypertension (-), DM (-), asthma (-), no history of allergy

to any food or medication Habits:

Alcohol (-) Smoking (-) NSAID use (-)

History of past illnesses (including surgery) None

History of family illnesses DM (-) Hypertension (+) in mother Cardiovascular disease (-) Cerebrovascular disease (-) Kidney disease (-) Hypercholesterolemia (-) Allergy (-), Asthma (-)

PHYSICAL EXAMINATIONGeneral Examination General condition: mildly ill State of consciousness: compos mentis Vital signs:

Blood Pressure : 110/70 mmHg Heart rate : 105 bpm Respiratory : 24 times/minute Temperature : 38,7oC

Body weight : 52 kg Body height : 160 cm Body mass index : 20.31 kg/m2 (normoweight)

Head : normocephal Eye : sclera icteric -/-, pale conjunctiva -/- ENT : discharge (-), blood (-), hyperemic pharynx

(-) Mouth : moist lip, cyanosis (-) Neck : no palpable mass or lymph nodes

Thorax Pulmonary examination

Inspection: symmetrical lung movement, scar (-) Palpation: symmetrical chest expansion and vocal fremitus, mass

(-), tenderness (-) Percussion: sonor at both lung field Auscultation: vesicular breath sound, crackles -/-, wheezing -/-

Cardiac examination Inspection: ictus cordis not visible Palpation: ictus cordis not palpable Percussion: right cardiac border at ICS IV right parasternal line, left

cardiac border at ICS V left mid-clavicular line, upper border at ICS III left parasternal line

Auscultation: normal S1/S2 regular, no murmur, no gallop

Abdomen Inspection: flat, no skin lesion/scar Auscultation: bowel sound (+) 3 times per minute Percussion: tympanic on four abdominal quadrant,

shifting dullness (-) Palpation: supple, skin turgor (+), tenderness (+) on

epigastrium, liver and spleen not palpable Extremities: CRT <2 seconds, warm distal extremities, no

edema, no deformities Rumple leed test was (-)

LABORATORY EXAMINATIONExamination

ResultReference Range

29/5/2015Hemoglobin 13 12 – 16 g/dLHematocrit 38 37 – 47%Leukocyte 4780 4,800 – 10,800/uLThrombocyte 145,000 150,000 – 400,000/uLElectrolyte

Sodium 143 135 – 147 mEq/LPotassium 3.7 3.5 – 4.5 mEq/LChloride 98 95 – 105 mmol/L

RESUME

Patient, 21 y.o female came with chief complaint of sudden onset of high fever since 20 hours before admission, was relieved with paracetamol for 4-5 hours. Nausea (+), vomit (+), headache (+), athralgia (+), myalgia (+), retroorbital pain (-), epistaxis (-), gum bleeding (-). Shortness of breath (-), abdominal pain (-). Thirst (+) PE: febris (38.7oC), tenderness (+) on epigastrium,

Rumple Leed test (-) Lab: thrombocytopenia, leukopenia

LIST OF PROBLEMS Fever

WORKING DIAGNOSIS1. Fever (1st day) caused by suspected viral infection Based on the characteristics of fever: sudden onset

of high fever, (+) flu-like symptoms athralgia, myalgia. On the physical examination there was fever and negative rumple-leed test.

Laboratory findings: leukopenia (support clinical findings) which is consistent with viral infection. Thrombocytopenia may also be found in various viral and bacterial infections.

RECOMMENDATION Further examination:

NS1 in dengue viral infection, NS1 test will yield (+) result from day 1 until day 3

Treatment Fever Paracetamol supp 1x1 Nausea and vomiting Domperidone 1x10mg

PRN, Ranitidin 2x150mg PO

EDUCATION Fluid intake 1-2L per day Bed rest Small frequent feeding Return to hospital if fever persist until 2-3

days

PROGNOSIS Quo ad vitam : ad bonam Quo ad sanationam : ad bonam Quo ad functionam : ad bonam

THANK YOU