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DENGUE HEMORRHAGIC

FEVER

Oleh:

Nucky Vera Arnaz, S.Ked

Rilahi Zahrah Harahap, S.Ked

Pembimbing:Prof.Dr.Zarkasih Anwar Sp.A(K)


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Case Report

IDENTIFICATION a. Name : AI

b. Age : 14 y.o c. Sex : Male d. Nationality : Indonesia e. Religion : Moslem

f. Address : Palembang g. Admitted to hospital : October, 28th

2011


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ANAMNESIS

Chief complain : Cool in feet andhands

Additional complain : red spots in feetand hands


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ILLNESSOFHISTORY


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5 days beforeadmission

2 days beforeadmission

-Still cold Red spots in extremities(feet and hands)

- High fever of unknownorigin, intermitten-Headache-Muscle pain-Epigastric pain

-Increased frecuent ofurination, yellowish colour

- Took medication but hiscomplain didnt decreased.


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6 hours before admission

-weak and cool in extremitiesWent to Bari Hospital, took IV line (RL 2 kolf), reconciled to theMohammad Hoesin Hospital

-History of past illness : Historyof DHF in July 2011-History of family disease: Historyof DHF on his family or neighbour

was denied


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History of pregnancy, growth anddevelopment, feeding, immunitation

unknown


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Physical Examination

General Examination (Oktober, 31st 2011) General condition : sick

Consciousness : Compos mentis

Weight : 44 kg

Height : 145 cm

Nutrition : normoweight

Blood Pressure : 110/70 mmHg

Pulse Rate : 78 x/minute

Suhu : 36, 1C

Respiration rate : 26 x/menit


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Specific examination

Skin :Petechiae

Head : Abnormality (-) Neck : Thyroid gland not palpable,

thyroid bruit (-)

Jugular vein pressure (5-2) cmH20 Thorax

Cor and lung : abnormality (-)

Extremities : cool extremities (+)


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Neurological Examination

Motoric function : Normal range Sensoric function : Normal range

Craniales nervus : Normal


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Additional Examination

Laboratory finding (28 Oktober 2011)

First examination

Blood analysis:

Hb : 16,4 g/dl Ht : 47 vol %

Leukosit : 3500/mm3

Trombosit : 36.000/mm3

Diff.count : 0/7/1/46/40/6


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Urine Analysis:

Sel epitel : (+)

Leukosit : 2-3/LPB

Eritrosit : 0-1/LPB

Silinder : (-)

Kristal : (-) Protein : (-)

Glukosa : (-)


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Hb = 16,4 15,8 15,5 15,9

Ht = 47% 45%46%40%

Trombosit = 360001700022000134000

IgG (+) dan IgM (+)


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DIAGNOSIS BANDING

DHF Grade III

Thypoid fever


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Working diagnose

DHF grade III


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TERAPI

MRS

IVFD RL 10cc/KgBB/jam (440 cc/ jam) Balance cairan per 6 jam

Banyak minum

Kurva suhu dan observasi tanda vital per 15menit

Rencana pemeriksaan lab : Hb, Ht,Trombosit, IgG dan IgM anti dengue


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PROGNOSIS

Quo ad vitam : Dubia ad Bonam

Quo ad functionam : Dubia ad

Bonam


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