Lapjag IGD 20-08-2014

DUTY REPORT20th AUGUST 2014

GP on duty : dr. Sere & dr. ArlisCo-ass on duty : Alvin & Dessy

PATIENTS RECAPITULATIONIn patient :

- Nn. R (DHF) our patient- Tn. B (pneumonia) Dead-Tn. U (dyspnoe observation)- Tn. A (suspect stroke hemorrhagic)- Ny. W (Gastritis)- Tn. D (lung carcinoma with metastasis to back bone)- Ny. W (hemoptysis)- Ny. F (dyspepsia syndrome)- Ny. S (Congenital Heart Failure)- Tn. D (Low intake and loss of consciousness)- Tn. H (pain on the right chest)

Out patient :- Tn. A (sinusitis)- Tn. J (syndrome dyspepsia)- Tn. F (…)Total patient : 15

PATIENT’S IDENTITY•Name : Ms. RF•Sex : Female•Place, Date of Born : Jakarta, February 7th 1993•Age : 21 years old•Job : Student•Religion : Moslem•Marital Status : Single•Ethnic/Race : Javanese•Address : Jl. Kayu Manis VIII, Matraman

History of Present IllnessChief complaint : Patient came to ER with chief complaint of

fever 5 days before admission.

The fever doesn’t have a specific time, and it goes fluctuating every day, had given drugs for her fever and she felt better, but after 4 hours, the fever came again. She had a complain of her arm and leg with a red spots from 3 days before admission. The red spots doesn’t diminished until she came to the hospital. She had an episode of gum bleeding spontaneously and when she flossed her teeth. She complained that she had red spots in both of her arms and legs. She still wants to eat and drink by herself.

She doesn’t have any complain like palpitation, excessive sweating, abnormal breathing.

Patient had a history of sore throat 5 days before admission, with no cough, and no symptoms of flu

No history of travelling to Kalimantan or Papua, flood areas, no history of rat bite.

No history of diarrhea, she had no complaint in urinating and no complain in defecation. She didn’t have any complain of black stool.

History of Past IllnessShe didn’t have any history of high blood

pressure, diabetes, and no history of heart disease, lung and renal disease.

She never experienced these symptoms before

History of family illness•She doesn’t have any history of high blood

pressure, diabetes and malignancy. •No family members have the similar symptoms

History of Socio-Habits•She neither smokes, drinks alcohol, nor uses

any forbidden drug. •She could still eat and drink well

Physical Examination•General State : Mildly sick•Consciousness : fully alert

Vital Signs•Blood Pressure: 90/60 mmHg•Heart rate : 88 bpm•Respiratory Rate : 18 times/minute•Temperature : 37.3 oC

•Body Weight : 54 kg•Body Height : 164 cm•BMI : 20.07 (Normoweight)

General Examination•Head : Normocephal

Eye : anemic conjunctiva (-/-), icteric sclera (-/-)

Ears : discharge (-)

Nose : septum deviation (-), discharge (-)

Mouth : coated tongue (-), hyperemic pharynx (-), normal T1-T1, pale mouth mucosa (-), dried mucosa (-)

•Neck : lymph nodes enlargement (-)

•Thorax: symmetric, intercostals retraction (-)

COR

Inspection: Ictus cordis (-)

Palpation: heave (-), lift (-), thrill (-)

Percussion:

Right border: ICS V, linea midclavicularis dekstra

Left border : ICS V, linea midclavicularis sinistra

Heart waist: ICS IV, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-)

▫ PULMO

• Inspection : chest within normal shape, symmetries on static and dynamic state

• Palpation : tactile vocal fremitus both lungs were symmetries, chest expansion symmetries

• Percussion : resonant both lungs

• Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

•Abdomen : flat, not distended,

timpani, no enlargement of liver & spleen

•Extremities: warm, petechiae on extremities (+), CRT < 2 seconds,

torniquet test (+)

Laboratory Results(20/08/2014) Hemoglobin: 12,8 g/dL Hematocrite : 38% Erytrocyte : 4.66 Leukocyte : 2670 Platelet : 82.000 MCV : 82.2 MCH: 27.5 MCHC : 33.4

RESUMEMs. RF, 21 years old, came to ER with the chief complaint of

fever 5 days before admission. The fever doesn’t have a specific time. She was given drugs for her fever and she felt better, but after 4 hours, it was recurrent. She complained of red spots around her arms and legs. The red spots did not disappeared until she came to the hospital. She had an episode of spontaneous gum bleeding when she flossed her teeth. She still wants to eat and drink by herself though.

Physical examination showed remarkable sign in both her legs and arms with spontaneous ptechieae, and torniquet test (+)

Laboratory results showed WBC 2670, Platelet 82.000/uL.

Diagnosis

•Working diagnosisDHF grade II

•Differential diagnosis▫Upper resp. tract infections▫Malaria▫leptospirosis

List of Problem

•DHF grade II

Discussion• DHF grade II, Based on: (WHO 1997)• HT and PE:

▫ history of sudden fever 2 – 7 days, biphasic▫ One or more than bleeding manifestation:

Tourniquet test (+) > 20 petechiae within 2,54 cm2

Ptecheiae, ecchymoses, or purpura Mucosal bleeding, GI bleed or others Hematemesis or melena

• Lab: ▫ Thrombocytopenia ( < 100.000/mm3) 82.000/mm3▫ One or more plasma leakage signs:

HCT > 20% compare to average HCT in ages, gender and population

HCT < 20% from baseline HCT after fluid therapy Evidence of pleural effusion, pericard effusion, ascites

and hypoproteinemia

Dengue fever grading• Grade I: Fever with untypical constitutional symptoms,

bleeding manifestation (+) by tourniquet test

• Grade II: Grade I with spontaneous bleeding

• Grade III: Compensated DSS (characterized by tachy- or bradycardia or hypotension, with cold skin and agitated)

• Grade IV:Uncompensated DSS (characterized by irregular blood pressure and heart rate)

Plan and Treatment• Non-

pharmacological interventions:▫ Bed rest▫ Oral fluid intake

max. 2L/day▫ Diet 1728 calories

• Pharmacological interventions:▫ IVFD RL 500 cc / 4

hours▫ Paracetamol tab.

500 mg, q8hr (On-demand)

Diagnostic plans: IgM – IgG anti

dengue

Monitoring plans: CBC q24hrs SGOT/SGPT Ureum/Creatinine Urine output Random blood

sugar

Prognosis•Quo ad Vitam : ad bonam•Quo ad Functionam : ad bonam•Quo ad Sanationam : dubia ad bonam

THANK YOU