MORNING REPORT

MORNING REPORTdr.Deddy - IPD

Friday, May 17th 2013PHYSICIAN IN CHARGE:

I A : dr.Deddy, dr.Asri, dr.Lenny (kardio)I B: dr.Ella, dr.AdityaII : dr.MartinIII : Laksmi S., Sp.PD

MODERATOR : dr.Supriono, Sp.PD-KGEHSUMMARY OF DATA BASEFemale/17 yo/W.28Chief complaint: FeverPatient suffered from high grade fever since 4 days ago, abruptly onset, and subsided when she took paracetamol but after 2 hours the fever was rising again. Headache since 4 days ago accompanied with myalgia and jpint fever. No gum bleeding nor nose bleeding.She complained nausea and vommite 1-2 times per day contained residual food and water since three days ago.She went to PHC Bareng two days ago, and diagnose dengue fever then got therapy paracetamol 3x1 tablet, antacida 3x1 tablet, vitamin 1x1 tablet.She had performed blood examination at PHC Bareng with result trombocyte 91.000, hmt 49, hb 14,4, leucocyte 4.100 There was no history of contact with his neighbours who suffered from dengue fever.

PHYSICAL EXAMINATIONBP : 100/60 mmHgPR : 84 bpm regular, strongRR : 18 tpmTax : 36.50CGeneral appearance : looked moderately illLooked normoweightGCS 456HeadPale conj. -NeckJVP R+0 cm H2OThorax : Cor Ictus invisible and palpable at ICS V MCL SLHM ~ ICS V MCL S, heart waist+RHM: SL DS1, S2 single with no murmurPulmo Symmetric, SF D=SAbdomenbowel sound N, liver span 10cm, traubes space tympaniExtremitiesRumple Leede +

LABORATORY FINDING:

ResultNormal ValueLeucocyte3.320/l 3.500 10.000Hemoglobine13,2gr/dl11.0 16.5MCV82,9Mm380-93 fLMCH26.70Pg27-31 fLEos/bas/neu/lim/mo0/3,3/57,6/33,4.5,7PCV39,4%35 50Trombocyte57.000/L150.000 390.000Ureum14,4mg/dL10-50Creatinine0,53mg/dL0.7 1.5SGOT96U/L11 41SGPT60U/L10 41Anti Dengue IgMNegativeAnti Dengue IgGPositivePPT11 secondK 11,9 sAPTT40,8secondK 25,5 s

CXR (plan for check this morning)CUE AND CLUEPLIDxPDxPTxPMoFemale/17yoAx:-High fever for 4 days , abruptly onset-Headache, myalgia, joint pain

PE:Rumple Leede +

Lab: PCV 39,4%Leuco 3.320Tromb 57.000Anti Dengue IgG +SGOT/SGPT: 96/60APTT 40,8 s (K 25,5 s)1.AFI day 4th+thrombo-cytopenia1.1.DHF grade I1.2.other arboviral infection1.3.Ricketsiosis

Weil Fellix-Diet 2100 kcal/day-IVFD Asering 5 cc/kgBW (250 cc) during 1-2 hour then IVFD Asering 3 cc /kgBW /hour during 2-4 hour, maintenance IVFD Asering 2100 cc/24 hour

-Po. Parasetamol 3x500 mg if Tax>37.5C-Surface cooling

VS,Bleeding,CBC serial

Female/17yoAx:-nausea and vommite2.Dyspepsiasyndrome1.1. dt no 11.2.PUD1Inj. Metochlopramide 3x10 mgPO: omeprazole 2x20 mgSubjCondition this morningGCS 456Subjective: fever subsidedBP: 100/60 mmHgHR: 82 bpm, regular, strongRR: 18 tpmTax: 36,1 C

Problem analysisDHF grade I Increase of transaminaseThrombocytopenia LeucopeniaDyspepsia syndrome Bleeding tendency 8RISK FACTORHigh rural populations in malaria-endemic areasTropical areas where the disease is commonTravelers from non-endemic areas to endemic areasGood nutritionHuman activities can create breeding sites for larvae (standing water in irrigation ditches, burrow pits) Agricultural work such as harvesting (also influenced by climate) may force increased night time exposure to mosquito bitesManagement AnalysisEmergency: -Urgency: IVFD Asering 5 cc/kgBW (250 cc) during 1-2 hour then IVFD Asering 3 cc /kgBW /hour during 2-4 hour, maintenance IVFD Asering 2100 cc/24 hour

Non urgency: -Diet 2100 kcal/day-Surface cooling -Inj. Metoclopramide 3x10 mg-PO: -omeprazole 2x20 mg -parasetamol if Tax>37.5C

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