Case for Analytic Skill

Feb 26th , 2013

Patient Identity

Name : ARP Sex : Male Age : 19 yo Nationality: Indonesia Occupation: Student Religion : Moeslem Address : Jl. Tukad Pancoran Kediri Tabanan TC : 13.23 Wita

Anamnesis
Chief complain : Fever

Patient has come with complaints of sudden high fever since 5 days BATH. Fever was continuous but reduced after consuming fever drug (paracetamol), but fever appeared again few hours later. Patient felt headache since 3 days BATH. Headache was felt along day and getting worsen when he did activities.

Anamnesis

Patients also complained of having muscle and joint pain. No bleeding from the gums, petechia or epixtasis. Normal consistency and coloration of stool and urination with normal frequency.

Past illness history

No history of having the same complaint before. History of asthma, hypertension, DM, and heart disease was denied by the patient. Medication history Paracetamol 3 x 500 mg for 3 days. Family history None of his family members have similar symptoms. Social history No neighbours have similar symptoms. Smoking (-), alcohol (-)

Physical Examination
Appearance Level of conciousness Blood pressure Temperatur axilla Pulse rate Respiratory rate Weight Height : Moderately ill : E4V5M6 : 120/80 mmHg : 37 OC : 80 x/min, reguler : 20 x/min : 50 kg : 160 cm

BMI

: 19,53 kg/m2

Physical examination
Status Present Eyes : Anemia -/-, ict -/- PR +/+ Isokor ENT : WNL Neck : Glands enlargement (-) JVP PR 0 cm H2O Chest examination HEART Insp : ictus cordis not visible Palp : ictus cordis not palpable Perc : UB: ICS II, RB: PSL D, LB: MCL S Ausc : S1S2 single regular murmur (-) LUNG Insp Palp Perc Ausc : symmetrical : vocal fremitus N/N : sonor/sonor : Vesicular +/+; ronchi -/-; wheezing -/-

Abdomen
inspection auscultation palpation : liver : spleen percussion : distention (-) : normal bowel sounds : unpalpable : unpalpable : tymphani

Extremities
warm + + edema + + tourniquet Test (+) - - -

Complete Blood Count (Feb 21st )

Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT

Result 3,3

Unit 103/L

Remarks L

Reference range 4,1 10,9 2,5 7,5 1,0 4,0 0,1 1,2 0,0 0,5 0,0 0,1 4,00 5,20 12,00 16,00

1,12 51.70 % 103/L Abdomen: Insp : distensi (-) 0.54 25.20 % Ausc : Bowel sound (+) 103/L normal 0.47 21.60 % 103 Palp : H/L not palpable /L 3 0.00 0.73% tenderness(-) 10 /L 0.00 0.82% 103/L Ballotment (-) 5.28 106/L Perc: Tympani (+) 15.60 48.10 82.50 28.70 34.80 11.50 114 g/dL %

Extremity: pitting edema

Pg %

, warm + + fL + +

36,0 46,0 80,0 100,0 26,0 34,0 31,0 36,0 11,0 14,8

g/dL 103/L L

150 440

Complete Blood Count (Feb 22nd )

Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT

Result 3,16

Unit 103/L

Remarks L

Reference range 4,1 10,9 2,5 7,5 1,0 4,0 0,1 1,2 0,0 0,5 0,0 0,1 4,00 5,20

1,12 51.70 % 103/L Abdomen: Insp : distensi (-) 0.54 25.20 % Ausc : Bowel sound (+) 103/L normal 0.47 21.60 % 103 Palp : H/L not palpable /L 3 0.00 0.73% tenderness(-) 10 /L 0.00 0.82% 103/L Ballotment (-) 5.28 106/L Perc: Tympani (+) 16.30 49.60 82.50 28.70 34.80 11.50 60 g/dL %

H H

12,00 16,00 36,0 46,0 80,0 100,0 26,0 34,0 31,0 36,0 11,0 14,8

Extremity: pitting edema

Pg %

, warm + + fL + +

g/dL 103/L L

150 440

ASSESSMENT
Susp. DHF gr. I (day 6)

TREATMENT
Hospitalized IVFD RL 30drips/min Paracetamol 3 x 500 mg Drink water 1,5-2 liters daily

PLANNING
Pdx:
Serologi DHF day VII

Monitoring
VS Complaints CBC @ 12 hours