DUTY REPORT

27
th
AUGUST 2014
GP on duty : dr. Ananita
Resident on duty : dr. Ardhestiro
Co-ass on duty : Alvin & Tedy

PATIENTS RECAPITULATION
3rd floor :
Mr. T > Myelodysplastic Syndrome
Mr. A > Anemia et causa hematoschezia

4th floor :

5th floor :
Mrs. W > intraabdominal mass with anaemia
Mrs. S > chronic diarrhea with HIV
Mrs. S> loss of consciousness et causa hypoglycaemia

6th floor :
Mr. W > Dengue Fever
Mr. R > Hemorrhagic shock
Mr. A > anaemia with Carcinoma nasopharynx
PATIENTS IDENTITY
Name : Mr. W
Sex : Male
Place, Date of Born : Jakarta, 21th November 1983
Age : 30 years old
Job : Army
Religion : Moslem
Marital Status : Married
Ethnic/Race : Javanese
Address : Komplek Nagrag, Bogor
Chief complaint : Patient came to ward with chief
complaint of fever 6 days before admission.

Additional complaint : headache, pain in his joint and
muscle, pain behind his eyeballs
4
History of Present Illness
History of Present Illness :
Patient came to the ward with the chief complaint of fever 6 days
before admission. The fever doesnt have a specific time, and it
goes fluctuating every day, had not given drugs for the fever but
patient went immediately to the hospital near his house. He
didnt have a complain of his arm and leg with a red spots from 3
days before admission. He complained about his pain in the
joint, muscle and behind his eye balls. He didnt have any
complained about spontaneous bleeding like gum bleeding or
nose bleed or dark stool. He still wanted to eat and drink by
himself.
He didnt have any complain like palpitation, excessive sweating,
abnormal breathing.
Patient didnt have a history of sore throat, no cough, and no
symptoms of flu, no history of heavy breathing

No history of travelling, go to flood areas, no history of rat bite.

No history of diarrhea, he had no complaint in urinating and no
complain in defecation.

He have a history of hypertension but it is not controlled by drugs
nor goes to the doctor or health care routine to check his blood
pressure
History of Past Illness
He didnt have a history of diabetes, kidney and lungs
disease
He had underwent cardiac catheterisation et causa
atherosclerosis
He never experienced these symptoms before
History of family illness
His mother suffered from hypertension
His father suffered from cardiac disease
No history of diabetes
No family members have the similar symptoms
History of Socio-Habits
He neither smokes, drinks alcohol, nor uses any
forbidden drug.
He could still eat and drink well
Physical Examination
General State : Mildly sick
Consciousness : Fully alert

Vital Signs
Blood Pressure : 120/70 mmHg
Heart rate : 88 bpm (regular)
Respiratory Rate : 18 times/minute
Temperature : 36.7
o
C

Body Weight : 75 kg
Body Height : 173 cm
BMI : 25.0 (Normoweight)
General Examination
Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric sclera (-/-)
Ears : discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth : coated tongue (-), hyperemic pharynx (-), normal T1-T1,
pale mouth mucosa (-), dried mucosa (-)
Neck : lymph nodes enlargement (-)
Thorax: symmetric, intercostals retraction (-)
COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dekstra
Left border : ICS V, linea midclavicularis sinistra
Heart waist: ICS IV, linea parasternal sinistra
Auscultation : regular 1
st
and 2
nd
heart sound, murmur (-),
gallop (-)
PULMO
Inspection : chest within normal shape, symmetries on static and
dynamic state
Palpation : tactile vocal fremitus both lungs were symmetries, chest
expansion symmetries
Percussion : resonant both lungs
Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

Abdomen : flat, not distended
timpani, no enlargement of liver & spleen
Extremities : warm, petechiae on extremities (-), CRT < 2 seconds, torniquet
test (-)
Laboratory Results
(27/08/2014)
Hemoglobin: 13.6 g/dL
Hematocrite : 38%
Erytrocyte : 5.0
Leukocyte : 4300
Platelet : 28.000
MCV : 76
MCH : 27
MCHC : 36



RESUME
Mr. W, 30 years old, came to ward with the chief complaint of fever 6
days before admission. The fever doesnt have a specific time, and it
goes fluctuating every day, had not given drugs for the fever but
patient went immediately to the hospital near his house. He didnt
have a complain of his arm and leg with a red spots from 3 days
before admission. He complained about his pain in the joint,
muscle and behind his eye balls. He didnt have any complained
about spontaneous bleeding like gum bleeding or nose bleed or
dark stool. He still wanted to eat and drink by himself.
He didnt have any complain like palpitation, excessive sweating,
abnormal breathing.

Physical examination showed normal sign
Laboratory results showed WBC 4300, Platelet 28.000/uL.
Diagnosis
Working diagnosis
Dengue fever

Differential diagnosis
Dengue Hemorrhagic Fever
Malaria
Urinary Tract Infection
Leptospirosis
List of Problem
Dengue Fever
Discussion
Dengue Fever, Based on:
HT and PE:
history of sudden fever 2 7 days, biphasic with 2 or more of
this sign or symptoms :
headache
retro orbital pain
myalgia
athralgia

Lab:
Thrombocytopenia ( < 100.000/mm
3
) 28.000/mm3
Leukopenia > 4300 with no sign of plasma leakage
Dengue fever grading
Dengue Fever : Fever with 2 or more symptoms like
headache, retro-orbital pain, myalgia, athralgia

Grade I: Fever with untypical constitutional symptoms,
bleeding manifestation (+) by tourniquet test

Grade II: Grade I with spontaneous bleeding

Grade III: Compensated DSS (characterized by tachy- or
bradycardia or hypotension, with cold skin and
agitated)

Grade IV:Uncompensated DSS (characterized by irregular blood
pressure and heart rate)
Plan and Treatment
Non-pharmacological
interventions:
Bed rest
Oral fluid intake max.
2L/day
Diet calories 2168
calories/day
Pharmacological
interventions:
IVFD RL 1800 cc / 24
hours
Diagnostic plans:
IgM IgG anti
dengue

Monitoring plans:
CBC q12hrs
Urine output
Prognosis
Quo ad Vitam : dubia ad bonam
Quo ad Functionam : ad bonam
Quo ad Sanationam : ad bonam
THANK YOU