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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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