DUTY REPORT EMERGENCY ROOM 3 RD FEBRUARY 2016 SEVERAL APPROACH TO PROBABLE DENGUE GP on duty: dr. Husna & dr. Fitria Co-ass on duty:Evan & Fauzan Supervisor : dr Soroy Lardo SppD FINASIM Division Tropical Medicine and Infectious Diseases Indonesia Army Central Hospital Gatot Soebroto
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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:
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,
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