MORNING REPORT CASE

March 30th, 2012

PATIENTS IDENTITY
Name Age Gender Religion Address Denpasar : LP : 19 yo : Male : Catholic : Jl. Gn Agung No 19,

ANAMNESIS

Chief complain :

Fever Present history : Patient came to the emergency unit with complaint of having fever since 4 days ago. This fever is said come abruptly and is felt very high without any shivering. Patient feeling better when he take medicine for fever, but the fever will come back again after it

Cont
Patient

also complaint having headache since 4 days ago and it feel like there is something pressing his head and feels better when he take a rest Patient also feel pain on all over his body since 3 days ago Patient had history of nose bleed 2 days ago. History of other bleeding was denied

Past illness history

History

of HT, DM, asthma, heart disease were denied

of HT, DM, asthma, heart disease were denied of smoking and drinking alcoholic drinks were denied

Family history
History

Social History :
History

PHYSICAL EXAMINATION
General appearance : Moderately ill Level of consciousness : Compos Mentis GCS : E4V5M6 Vital Sign: BP : 110/80 mmHg RR : 18 x/min PR : 78 x/min tax : 37,4C Body weight : approx 56 kg Height : approx 170 cm BMI : 19,3 kg/m2

Eyes

: conj. Pale (-/-); icterus (-/-); Rp +/+ isocore

ENT : WNL Neck : JVP RP + 0 cmH2O; lymph node enlargement (-)

Thorax : Symmetric, retraction (-) Cor Inspection : Ictus cordis not visible Palpation : Ictus cordis not palpable Percussion : UB : ICS II LB : MCL S ICS V RB : PSL D Auscultation : S1 S2 single regular, murmur (-) Po Inspection : Symmetrically static and dynamic Palpation : VF normal/normal Percussion : sonor/sonor Auscultation : Bronchovesikular +/+ , Rh -/-, wh -/-

Abdomen : Inspection Auscultation Percussion Palpation palpable

: Distention (-) : Bowel sounds (+) normal : Tympani : Liver & spleen not

Extremities: Warm +/+ edema -/+/+ -/-

Complete blood count

Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT MPV 41,2% 41,3% 15,4% 0,2% 0,9% 5,41 15,2 44,6 82,3 28,1 34,2 13,4 59,00 7,3 Result 2,9 1,2 1,2 0,4 0,0 0,0 Unit 103/L 103/L 103/L 103/L 103/L 103/L 106/L g/dL % fL pg g/dL % 103/L fL L Remarks L Reference range 4,5 11,00 47,00 80,00 13,0 40,0 2,00 10,00 0,00 5,00 0,0 0 2,00 4,50 5,90 13,50 17,50 36,00 46,00 80,00 100,00 26,00 34,00 31,00 36,00 11,60 14,90 150,0 440,0 6,80 10,00

Blood chemistry panel

Parameter Albumin
Natrium Kalium

Result 4,18
134,00 4,26

Unit mg/dL
mmol/L mmol/L

Remarks

Reference range 3,40 4,80

136,00 145,00 3,5 5,1

ASSESMENT

Susp DHF gr II (5th day) - Epistaxis

PLANNING

Therapy
Hospitalized IVFD

NaCl 0,9% 30 dpm Paracetamol 3x500 mg (if needed)

Diagnosis
Dengue

serology 7th day

Monitoring
Vital

signs, complaints Fluid Balance CBC @ 8 hours

THANK YOU