MR 16 april DHF Gr I

7/28/2019 MR 16 april DHF Gr I

1/15

April 16th , 2013


2/15

Name : NKA Sex : Female Age : 15 yo

Nationality : Indonesia Occupation : Student Religion : Hindu Address : Br Sedahan, Mengwi ToA : April15th, 2013


3/15

Chief complain : Fever

Patient came with complaints of sudden highfever since 4 days BATH. Fever was continuousbut reduced after consuming fever drug(paracetamol) from public health centre, butfever appeared again few hours later.

Patient complained nausea and sometimesvomitting after eating food along 4 days BATH.

The vomits contain food and water about a cupof glass. The illness getting better in the April14th 2013 about 15.00 WITA until the day ofadmission to the hospital.


4/15

Patient felt headache since 4 days BATH.

Headache was felt along day and getting

worsen when she did activities.

Patients also complained of having muscle

and joint pain.

No bleeding from the gums or epixtasis.

Normal consistency and coloration of stooland urination with normal frequency.


5/15

Past illness historyNo history of having the same complain before.

History of hypertension, DM, and heart disease wasdenied by the patient.

Medication historyParacetamol 3 x 500 mg and Ondansentron 2 x 8mg for 3 days.

Family historyNone of her family members have similar symptoms.Social historySome neighbours have similar symptoms andadmitted to the hospital.Smoking (-), alcohol (-)


6/15

Appearance : Moderately ill

Level of conciousness : E4V5M6

Blood pressure : 100/70 mmHg

Temperatur axilla : 37,8OC

Pulse rate : 88x/min, regular

Respiratory rate : 20 x/min

Weight : 50 kg

Height : 160 cm

BMI : 19,53 kg/m2


7/15

Status Present

Eyes : Anemia -/-, ict -/- PR +/+ IsokorENT : WNLNeck : Glands enlargement (-) JVP PR 0 cm H2OChest examination

HEART

Insp : ictus cordis not visiblePalp : ictus cordis not palpablePerc : UB: ICS II, RB: PSL D, LB: MCL SAusc : S1S2 single regular, murmur (-)

LUNGInsp : symmetricalPalp : vocal fremitus N/NPerc : sonor/sonorAusc : Vesicular +/+; ronchi -/-; wheezing -/-

Physical examination


8/15

Abdomen

inspection : distention (-)

auscultation : normal bowel soundspalpation : liver : unpalpable

: spleen : unpalpable

percussion : tymphani

Extremitieswarm + + edema - -

+ + - -

Tourniquet Test (+)


9/15

Abdomen: Insp : distensi (-)

Ausc : Bowel sound (+) normal

Palp : H/L not palpable

tenderness(-)

Ballotment (-)

Perc: Tympani (+)

Extremity: pitting edema , warm- -- -

+ ++ +

Parameter Result Unit Remarks Referencerange

WBC 4,18 103/L L 4,1 10,9

-Ne 2,76 66.00 % 103/L 2,5 7,5

-Ly 0.77 18.40 % 103/L 1,0 4,0

-Mo 0.65 15.60 % 103/L 0,1 1,2

-Eo 0.00 0.0% 10

3

/L 0,0 0,5-Ba 0.00 0.0% 103/L 0,0 0,1

RBC 4,29 106/L 4,00 5,20

HGB 11,8 g/dL 12,00 16,00

HCT 35,2 % 36,0 46,0

MCV 82.10 fL 80,0 100,0

MCH 27.50 Pg 26,0 34,0

MCHC 33.50 g/dL 31,0 36,0

RDW 13,3 % 11,0 14,8

PLT 114 103/L L 150 440


10/15

Abdomen: Insp : distensi (-)

Ausc : Bowel sound (+) normal

Palp : H/L not palpable

tenderness(-)

Ballotment (-)

Perc: Tympani (+)

Extremity: pitting edema , warm- -- -

+ ++ +

Parameter Result Unit Remarks Referencerange

WBC 3,23 103/L L 4,1 10,9

-Ne 1,95 60.40 % 103/L 2,5 7,5

-Ly 0.87 26.90 % 103/L 1,0 4,0

-Mo 0.41 21.60 % 103/L 0,1 1,2

-Eo 0.00 0.0% 10

3

/L 0,0 0,5-Ba 0.00 0.0% 103/L 0,0 0,1

RBC 4,43 106/L 4,00 5,20

HGB 12,2 g/dL 12,00 16,00

HCT 36,5 % 36,0 46,0

MCV 82.40 fL 80,0 100,0

MCH 27.50 Pg 26,0 34,0

MCHC 33.40 g/dL 31,0 36,0

RDW 13,4 % 11,0 14,8

PLT 94 103/L L 150 440


11/15

Investigation Result NormalS. Thyphi H Negative

Titer


12/15

Susp. DHF gr. I (day 4)


13/15

Hospitalized

IVFD RL 30drips/min

Paracetamol 3 x 500 mg

Ondansentron 2 x 8 mg prn


14/15

Pdx:Serology DHF day VIIMonitoringVS

Complaints

CBC @ 12 hours

PLANNING


15/15

MR 16 april DHF Gr I

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