Case analysis Probable dengue base on WHO Guidelines 2009

1. DUTY REPORT
EMERGENCY ROOM
3RD 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

2. 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

3. 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

4. ANAMNESIS
 Autoanamnesis
 Chief complaint:
 Fever for 20 hours before admission
 Additional complaints:
 Nausea and vomiting
 Headache

5. 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 (+)

6.  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

7.  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

8.  History of family illnesses
 DM (-)
 Hypertension (+) in mother
 Cardiovascular disease (-)
 Cerebrovascular disease (-)
 Kidney disease (-)
 Hypercholesterolemia (-)
 Allergy (-), Asthma (-)

9. PHYSICAL EXAMINATION
General Examination
 General condition: mildly ill
 State of consciousness: compos mentis
 Vital signs:
 Blood Pressure : 110/70 mmHg
 Heart rate : 105 bpm
 Respiratory : 24 times/minute
 Temperature : 38,7oC
 Body weight: 52 kg
 Body height : 160 cm
 Body mass index : 20.31 kg/m2 (normoweight)

10.  Head : normocephal
 Eye : sclera icteric -/-, pale conjunctiva -/-
 ENT: discharge (-), blood (-), hyperemic pharynx (-)
 Mouth : moist lip, cyanosis (-)
 Neck : no palpable mass or lymph nodes

11.  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

12.  Abdomen
 Inspection: flat, no skin lesion/scar
 Auscultation: bowel sound (+) 3 times per minute
 Percussion: tympanic on four abdominal quadrant, shifting
dullness (-)
 Palpation: supple, skin turgor (+), tenderness (+) on
epigastrium, liver and spleen not palpable
 Extremities: CRT <2 seconds, warm distal extremities, no edema,
no deformities
 Rumple leed test was (-)

13. LABORATORY EXAMINATION
Examination
Result
Reference Range
29/5/2015
Hemoglobin 13 12 – 16 g/dL
Hematocrit 38 37 – 47%
Leukocyte 4780 4,800 – 10,800/uL
Thrombocyte 145,000 150,000 – 400,000/uL
Electrolyte
Sodium 143 135 – 147 mEq/L
Potassium 3.7 3.5 – 4.5 mEq/L
Chloride 98 95 – 105 mmol/L

14. RESUME
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

15. LIST OF PROBLEMS
 Fever

16. WORKING DIAGNOSIS
1. 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.

18. 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

19. EDUCATION
 Fluid intake 1-2L per day
 Bed rest
 Small frequent feeding
 Return to hospital if fever persist until 2-3 days

22. PROGNOSIS
 Quo ad vitam : ad bonam
 Quo ad sanationam : ad bonam
 Quo ad functionam : ad bonam

23. THANK YOU