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DUTY REPORT

27th

AUGUST 2014

GP on duty : dr. Ananita

Resident on duty : dr. Ardhestiro

Co-ass on duty : Alvin & Tedy

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PATIENTS RECAPITULATION

3rd floor :Mr. T > Myelodysplastic SyndromeMr. A > Anemia et causa hematoschezia

4th floor :

5th floor :Mrs. W > intraabdominal mass with anaemiaMrs. S > chronic diarrhea with HIVMrs. S> loss of consciousness et causa hypoglycaemia

6th floor :Mr. W > Dengue FeverMr. R > Hemorrhagic shockMr. A > anaemia with Carcinoma nasopharynx

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PATIENTS IDENTITY

Name : Mr. WSex : Male

Place, Date of Born : Jakarta, 21th November 1983Age : 30 years oldJob : ArmyReligion : Moslem

Marital Status : MarriedEthnic/Race : JavaneseAddress : Komplek Nagrag, Bogor

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Chief complaint : Patient came to ward with chiefcomplaint of fever 6 days before admission.

Additional complaint : headache, pain in his joint andmuscle, pain behind his eyeballs

4

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History of Present Illness

History of Present Illness:Patient came to the ward with the chief complaint of fever 6 daysbefore admission. The fever doesnt have a specific time, and it

goes fluctuating every day, had not given drugs for the fever butpatient went immediately to the hospital near his house. Hedidnthave a complain of his arm and leg with a red spots from 3days before admission. He complained about his pain in thejoint, muscle and behind his eye balls. He didnt have any

complained about spontaneous bleeding like gum bleeding ornose bleed or dark stool. He still wanted to eat and drink byhimself.

He didnthave any complain like palpitation, excessive sweating,abnormal breathing.

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Patient didnt have a history of sore throat, no cough, and no

symptoms of flu, no history of heavy breathing

No history of travelling, go to flood areas, no history of rat bite.

No history of diarrhea, he had no complaint in urinating and nocomplain in defecation.

He have a history of hypertension but it is not controlled by drugs

nor goes to the doctor or health care routine to check his bloodpressure

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History of Past Illness

He didnt have a history of diabetes, kidney and lungsdisease

He had underwent cardiac catheterisation et causaatherosclerosis

He never experienced these symptoms before

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History of family illness His mother suffered from hypertension

His father suffered from cardiac disease

No history of diabetes No family members have the similar symptoms

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History of Socio-Habits

He neither smokes, drinks alcohol, nor uses anyforbidden drug.

He could still eat and drink well

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Physical Examination

General State : Mildly sick Consciousness : Fully alert

Vital Signs

Blood Pressure : 120/70 mmHg Heart rate : 88 bpm (regular) Respiratory Rate : 18 times/minute Temperature : 36.7 oC

Body Weight : 75 kg Body Height : 173 cm BMI : 25.0 (Normoweight)

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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 (-)

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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 1stand 2ndheart sound, murmur (-),

gallop (-)

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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 (-)

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Laboratory Results(27/08/2014)

Hemoglobin: 13.6 g/dL

Hematocrite : 38%

Erytrocyte : 5.0

Leukocyte : 4300 Platelet : 28.000

MCV : 76

MCH : 27

MCHC : 36

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RESUMEMr. W, 30 years old, came to ward with the chief complaint of fever 6

days before admission. The fever doesnthave a specific time, and itgoes fluctuating every day, had not given drugs for the fever butpatient went immediately to the hospital near his house. He didnt

have a complain of his arm and leg with a red spots from 3 daysbefore admission. He complained about his pain in the joint,muscle and behind his eye balls. He didnt have any complainedabout spontaneous bleeding like gum bleeding or nose bleed ordark stool. He still wanted to eat and drink by himself.

He didnt have any complain like palpitation, excessive sweating,abnormal breathing.

Physical examination showed normal sign

Laboratory results showed WBC 4300, Platelet 28.000/uL.

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Diagnosis

Working diagnosis

Dengue fever

Differential diagnosis

Dengue Hemorrhagic Fever

Malaria Urinary Tract Infection

Leptospirosis

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List of Problem

Dengue Fever

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Discussion Dengue Fever, Based on:

HT and PE:

history of sudden fever 2 7 days, biphasic with 2 or more of

this sign or symptoms:

headache

retro orbital pain

myalgia

athralgia

Lab: Thrombocytopenia ( < 100.000/mm3) 28.000/mm3

Leukopenia > 4300 with no sign of plasma leakage

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Dengue fever grading

Dengue Fever : Fever with 2 or more symptoms likeheadache, retro-orbital pain, myalgia, athralgia

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 andagitated)

Grade IV:Uncompensated DSS (characterized by irregular bloodpressure and heart rate)

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Plan and Treatment Non-pharmacological

interventions:

Bed rest

Oral fluid intake max.2L/day

Diet calories 2168calories/day

Pharmacologicalinterventions:

IVFD RL 1800 cc / 24hours

Diagnostic plans:

IgM IgG antidengue

Monitoring plans:

CBC q12hrs

Urine output

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Prognosis

Quo ad Vitam : dubia ad bonam

Quo ad Functionam : ad bonam

Quo ad Sanationam : ad bonam

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THANK YOU