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MORNING CASEMORNING CASE

REPORTREPORT June 3 June 3rdrd, 201, 20166

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AnamnesisAnamnesis

Chief Complain : Fever Present history 

*a'ien' +ame $rom ,ome -i', +omplain' o$

sudden $e%er sin+e 6 days .A#H( Fe%er-as suddenly ,ig, and +on'inuous(

#,e 'empera'ure redu+ed a$'er s,e 'oo/

',e medi+ine bu' ',en ,er $e%er in+reased

again( Her 'empera'ure -as ! 23(

#,e 'empera'ure redu+ed sin+e ',e day o$

admission(

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AnamnesisAnamnesis

Present history (cont)

She als !m"lained a#u$ nausea and

%mi$in& sin!e 2 da' (AT) and "a$ien$ has

%mi$$ed 6 $imes n $he da' (AT)*

 There +as n si&n nse and &um #leedin& *

-rina$in and dee!a$in +as said $ #e

nrmal*

 The +as n #rea$hlessness, !u&h, r runn'nse*

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Past illness history No ,is'ory o$ ,a%ing ',e same +omplain' be$ore(

His'ory o$ as',ma ,yper'ension DM and ,ear'disease -as denied by ',e pa'ien'(

Family history 

None o$ ,er $amily members ,a%e similarsymp'oms(Family ,is'ory o$ as',ma diabe'es melli'us,yper'ension and ,ear' disease -as denied(

Social history No neig,bours or asso+ia'es ,a%e similarsymp'oms(Smo/ing 5 al+o,ol 5

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Physical examinationPhysical examination

Present statusA""earan!e . Mdera$el' illCns!iusness . E/M6(ld "ressure . 1100 mm)&A4illar' Tem"* . 35,3 OCPulse ra$e . 2 #"m, re&ularRes"ira$r' ra$e . 20 4min7ei&h$ . 6 8&)ei&h$ . 16 !m(MI . 23,5 8&m2

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General Statusyes : Anemi+ 5&5 i+'erus 5&5 *upilRe8ex 9

N# : pis'axis 5Mou', : ,is'ory o$ um .leeding 5Ne+/ : ;3,es' examina'ion

Hear'?nsp : i+'us +ordis no' %isible*alp : i+'us +ordis no' palpable*er+ : @.: ?3S ?? R.: *S D .: M3 S

 Aus+ : S1S single regular murmur 5

ung?nsp : symme'ri+al s'a'i+ and dinami+*alp : 'a+'ile $remi'us N&N*er+ : sonor&sonor

Physical examinationPhysical examination

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A#dmenins"e!$in . 9is$en$in :;<aus!ul$a$in . Nrmal #+el sunds"al"a$in . =i%er . un"al"a#le

  . S"leen . un"al"a#le. Tenderness :;<

"er!ussin . T'm"ani

E4$remi$ies+arm > > edema ; ;

> > ; ;

Physical examinationPhysical examination

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Cm"le$e (ld Cun$ :0362016< nrmal

  Pal" . )= n$ "al"a#le

  $enderness:;<  (all$men$ :;<

Per!. T'm"ani :><

E4$remi$'. "i$$in& edema , +arm- -

- -

+ +

+ +

Parameter Result Unit Remarks Reference range

WBC 2.! "#!$%& &o' ()" * "#)

;,e (()#( &o' ()# * #)#

;&y (#.(/ "!)# * (#)#

;0o !.2# 1igh 2)# * "")#

;o #." #)# * 3)#;Ba ".2# #)# * #)"

RBC (.3 "#/$%& ()## * 3)2#

14B "!.2# g$d& "2)## * "/)##

1C5 (2. 1igh !/)# * (/)#

0C6 2. f& #)# * "##)#

0C1 2.2# 7g 2/)# * !()#

0C1C !#.# g$d& !")# * !/)#

R8W "".! "")# * "()

P&5 !/.( "#!$%& &o' "3# * ((#

0P6 ""."# f& /) * "##)#

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9ssessment9ssessment

Suspect DHF Grade I day VI 

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5reatment5reatment

 Hospitalized

 IVFD RL 30 dpm

 Paracetamol 3x500mg (PO) (if eeded)  Domperido 3x!0 mg (PO)

 "ieral #ater ita$e !%5 & ' liters dail

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Plannin& 9ia&ns$i!9en&ue serl&i! $es$ :I&GI&M an$i

den&ue< n $h da'

Mni$rin&S, Cm"lain$sC(C ? 12 hurs

Planning

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