CASE REPORT

THURSDAY, 20 JULI 2017

SUPERVISOR:
dr. Saptadi Yuliarto, Sp.A(K), M.Kes

Presenter :
Vincent Jegou
 IDENTITAS

Name : NF
Age : 13 years old
Gender : Male
Address : Kedung Kandang
Hospitalized : 9th, July 2017
Register Number :1134xxxx
 Parents Data

Father Mother
Age: 34 yo Age: 35 yo
Occupacy : technicians Occupacy : housewife
 ANAMNESIS
MAIN COMPLAIN : Fever, nausea, vomiting

History of present illness

- He camped from 7/7/2017 to 9/7/2017in Jombang.
- Fever since 7/7/2017 : high fever at the beginning and then decreased with antipyretics
and then rise again until 11/07/2017
- Nausea and vomiting (+) 2 times contains foods, 100cc
- Contact with dengue (-)

History of Medication
Came to Primary Health Care in Jombang, given
- PCT
- thiamphenicol
- amoxicilin (only consumed 1 tablet)
History of Past Disease (-)

History of Family disease:

Family with same complain (-)

Social History :
He is the first child of 4 siblings
II/male/7 yo
III/male/3yo
IV/female/3yo

History of vaccination :
Complete according to his mom
History of Labor :

Aterm, 3.5kg, cry immedietly, icteric (-), apneu (-), bad odor (-)

History of pregnancy :

ANC 6 months, DM (-), HT (-), fever (-), bleeding (-), vaginal

discharge (-), no vomiting and nausea, increased weight
10kgs

History of intake :

- Birth 4 months : breastfeed

- 4 months - now : Formulation milk

- 6months 12 months : Soft meal

- 1 year now : Family dishes

 Physical Examination

General status :
Looked mildly sick
Compos mentis

Vital sign :
HR 120x/menit
RR 28x/menit
Temperature 38,2C
SpO2 98%
 Head
Nose : rainny nose (-)
Ear : normal
Mouth and throat: normal
Eyes: normal
Neck
Lymphoadenopathia (-)
Thorax
Heart : S1 S2 normal, murmur -, gallop
Lung : ronkhi (-), whezzing (-)
Others : Retraction (-)
Abdomen
Liver : splenomegaly(-)
Spleen : hepatomegaly (-)
Stomach : stomach pain on the 11/07
Others : ascites on the 11/07
 Extremity
Clubbing (-)
Cyanosis (-)
Oedema (-)
Neurology
Sensory : normal
Motricity : normal
 Anthropometry
Weight : 50 kg (P50 - P75)
Height : 158 cm (P50 P25)
HC : 56 cm
AC : 23 cm
Ideal weight : 47kg
 PLANNING DX

Complete blood count

NS 1
Serology
 LABORATORY
9/07 10/07 11/07 11/07 12/07 12/07 13/07 13/07 14/07
10:30 23:00 13:00 19:00 1:00 14:00

ue Lab Value
Hb 15 15,5 16 16,2 16,4 16,1 15,7 15,7 14,7
Hemoglobin 12,2 11.4-15.1 g/dl Natrium 131 136-145 mmol/L
Hct 44 44,6 47 46,5 45,9 45,2 43,3 44,3 41,5
Leukosit 9,68 4,7-11,3 x 10^3/l Kalium 4,05 3,5-5,0 mmol/L
Trb 121 100 45 28 21 18 9 15 23
Eritrosit 4,66 4-5 x 10^6/l Clorida 101 98-106 mmol/L
Leu 3130 2690 1460 2140 1920 1920 2760 3280 3870
HCT 32,6% 38-42%
Asat
Trombosit 67 176.000 363
142.000-424.000
MCV
Alat 30 70 80-93 fL 109
MCH
Na 26 27-31 pg
129
MCHC
K 37,1 32-36 g/dL
3,93
Eu/bas/Neu/Ly/ 0/0.1/58,4 0-4/0-1/51-67/25-
Cl 102
Mo /24,9/16,6 33/2-5 %
Ca 8,8
Blood sugar 137 <200
P 5,3
Alb 3,86 3,71
MCV 88,6 88,7 88,3 86,8 85,6 83,7 82,5

MCH 29,5 30,8 30,1 30,2 30,6 29,8 29,9

MCHC 34,1 34,8 34 34,8 35,7 35,6 36,3
RWD 12 12,1 12,2 11,9 11,8 11,7 11,5
 WORKING DX

Dengue Hemorragic Fever, grade 1

 Therapy

IVFD C1:500cc /24h

Intravena :
PCT 3x500mg
PO :
Multivit 1/6h
Diet : Nasi TKTP 3x1
09/07 C1:1 500cc

10/07 C1:1. 1000cc

11/07 C1:1. 1000cc

12/07 C1:1. 2000cc

13/07 C1:1. 1500cc

14/07 C1:1. 500cc

 Parents Education:
The disease
Dangerous sign
 MONITORING PLAN

Vital sign
Fever
Nausea and vomiting
Laboratory :
- Hc
. - Trb
TERIMA KASIH