Professional Documents
Culture Documents
Presented by :
M. Fahrizal Alkaff
0010035
Counsellor :
H. Tisna Sukarna, dr, SpA, MBA
DEPARTMENT OF PEDIATRIC
MEDICAL FACULTY
MARANATHA CHRISTIAN UNIVERSITY
BANDUNG
2006
I. Patient Identification
2.5. Immunizations
Booster Recommended
Vaccine Basic Vaccination
Vaccination Vaccination
BCG √ (scar + ) - - - HiB : none
Polio √ √ √ - - - MMR : none
DPT √ √ √ - - - Hep A : none
Hep B √ √ √ - - - Varicella : none
Measles √ - - - Typhim/typha : none
Inluenzae : none
3.2.Vital signs
Pulse : 102 times a minute, weak pulse
Respiration : 36 times a minute, abdominothoracal type
Temperature : 37,4 ºC, axillar
Blood pressure : 90/60 mmHg
Rumple Leede : Not performed
3.3. Measuring
Age : 7 years, 3 months
Weight : 20 kg
Height : 118 cm
( 88.89 % standard Weight/Age )
( 96.72 % standard Height/Age )
( 96.15 % standard Weight/Height )
Nutrition status : good (standard Weight/Height )
Circumference of the head : 51 cm
Circumference of the chest : 64 cm
Circumference of the abdomen : 68 cm
Circumference of the upper arms : 22 cm
4.3. Neck
Nuchal rigidity : –
JVP : 5+0 cmH2O
Lymph node : not palpable
4.4. Thorax
Lungs
Inspection : shape and movement was simetric, right was equal to left,
retractions -
Palpation : vocal fremitus right was equal to left
Auscultation : vesicular breath sound +/+, rales -/-, wheezing -/-
Heart
Inspections : ictus cordis was not seen
Palpations : ictus cordis was palpable at ICS 4 linea midclavicularis
sinistra
Percussions : border on top ICS 2 linea parasternalis sinistra
border on left ICS 4 linea midclavicularis sinistra
border on right ICS 3 linea sternalis dextra
Auscultations : heart sounds regular, shouffle -
4.5. Abdomen :
Inspections : flat
Auscultations : bowel sound + normal
Percussions : tympanic, Traube’s space : tympanic
Palpations : soepel, tenderness +, skin’s turgor was immediately returns
to its normal position
liver palpable ± 3 cm BAC (flat surface, sharp edge, tough
consistency, not painful to press)
spleen unpalpable
kidney unpalpable
4.6. Genital : female, normal
4.7. Anus & Rectal : no disparity
4.8. Extremities : no disparity, cold acral
Upper : left: active, right : active
Lower : left: active, right: active
Joint : no disparity
Muscle : hypertrophy -, atrophy -
Reflex : physiological +/+, pathological -/-
4.9. Neurological Examination
Reflex : physiological +/+, pathological -/-
V. Laboratory finding
17/02/2006 (patient was moved to PICU time : 13.00)
Hb : 11,8 gr/dl
Hct : 35 %
Trombocyte : 28.000 / mm3
Anti Dengue IgM +, IgG +
18/02/06
Hb : 13,4 gr/dl
Hct : 41 %
Trombocyte : 30.000 / mm3
19/02/06 time : 06.20
Hb : 14,2 gr/dl
Hct : 43 %
Trombocyte : 53.000 / mm3
time : 16.45
Hb : 12,5 gr/dl
Hct : 37 %
Trombocyte : 80.000 / mm3
20/02/06
Hb : 11,7 gr/dl
Hct : 36 %
Trombocyte : 125.000 / mm3
17/02/2006
Chest X-Ray : Impression : There was a pleural effusion dextra
VI. Resume
Seven years old girl, with 20 kg body weight, nutritional status good (96.15%
standard Weight/Height ) came to Immanuel Hospital with febris as a chief complain.
Five days before hospitalization, the patient had febris, suddenly high and
continuous, night temperature higher than daytime. The temperature was decrease
using drugs. The patient had headache, myalgia, anorexia and queasy too.
Three days before hospitalization, there was a red spots on patient’s skin.
Two days before hospitalization, the patient had vomit two times a day, each
vomit is about quarter of glass, contains water and food residue. She also had gum
bleeding.
Mixie : the colour is yellow, normal in frequency and volume.
Defecation : since 5 days before hospitalization the patient only defecate one time, it
was diarrhea with no blood or mucus
Past medical history : The patient had haven’t illness like this
Record of family health : his family denied got sick like this.
Medical effort : The patient had seen a doctor in Cimahi, and told that she had
fever. The doctor gave medicine to went down her temperature,
also Ikadryl® cough syrup and antibiotics.
2. Medicamentous
- Adona 50 mg in Ringer Lactate 500 cc IV (17/02/06-21/02/06)
- Fixef 2x500 mg IV (17/02/06-21/02/06)
- Kalfoxim 2x500 mg IV (17/02/06-21/02/06)
- Transbroncho 3x1 cth (17/02/06-21/02/06)
- Imunos 2 x 1 cth (17/02/06-21/02/06)
- Lasix 10 mg (17/02/06)
- Longcef 2 x 1 cth (20/02/06-21/02/06)
- Igastrum 3x1 cth (20/02/06-21/02/06)
X. Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
XI. Discussion
The Diagnosis of DHF Grade III based on :
Anamnesis :
Five days, suddenly high fever and continue
Headache and myalgia
Weak, anorexia, queasy, vomit
Petechie, gum bleeding
Physical Verification :
The patient looks snivel
Weak pulse, tachycardi, tachypneu
Hepatomegaly
Cold acral
Laboratory Finding
- Trombocytopenia
- Chest X-Ray : there was right pleural effusion
XII.REFERENCES
Introduction
Dengue virus is an arthropod borne virus belonging to genus flavivirus, family
flavividae. There are four serotypes called DEN-1, DEN-2, DEN-3, DEN-4. Infection
with one serotype provides lifelong immunity for homologous infection but no croos
protection against infection with other serotype. Aedes aegypty as the principle vector
in India. It is a small black and white tropical masquito. It rests indoors and bites
humans in daytime. It lay eggs in water collected in artificial countainers like buckets,
coolers, flower pots. Its incubation period is about 10-12 days.
Pathophysiology
Exact mechanism of DHF/DHS is not clear, two theories, one, the secondary infection
or immune enhancement hyapotesis. This hypotesis implies that patient
experiencing a second infection with a heterogeneous dengue virus serotype has a
significantly higher risk for developing DHS and DSS. Preexisting heterologous
dengue antibody reconizes the infecting virus and forms an antigen antibody complex,
which is then bound to and internalized by immunoglobulin Fc receptors on the cell
membrane of leukocytes, expecially macrophages where virus is free to replicate. This
antibody dependent enhancement (ADE) enhances the infection and replication of
dengue virus in cells of the mononuclier cell lineage. These cell produce and secrete
vasoactive mediators in response to dengue infection, which causes increase vascular
permeability leading genome may include increased virus replication and viremia,
virulence (severity of deases), and epidemic potential. Cytokines and chemical
mediators such as tumor necrosis factor (TNF), INTERLEUKIN-1 (IL-1), IL-2, IL-6,
platelet activation factor (PAF), complement activation products C3a and C5a, and
histamine may play a role.
Manifestations
A. Asymptomatic-
B. Symptomatic-(i) Undifferentiated Fever, (ii) Dengue Fever (a) Without
Hemorrage (b) With Unusal Hemorrage. (i) DHF without shock (ii) DHF with shock.
Symptoms
Fever usually starts after 2-7 days after masquito bites. It is associated with mascular
or maculopapular rash. Vomiting, diarhoea, abdominal pain, convulsions, altered
sensorium, headache, retro-orbital pain, arthralgia are usually associated.
Hepatomegaly, splenomegaly, bradycardia, lyphadenopathy is usual findings. In DHF
the hemorrage starts by third day. It is characterised by positive torniquet test (Hess
test), epistaxis, hematemesis, skin/mucosal bleeds, melana. Thrombocytopenia (less
than 1,00,000 per cmm) and evidence of plasma leak are characteristic of DHF. The
plasma leak is to be monitored by more than 20% rise in hematocrit for age, more
than 20% drop in hematocrit following treatment with fluids as compared to base line.
DSS includes all about and above and signs of circulatory failure manifested by rapid
and weak pulse, narrow pulse pressure, hypotension for age.
DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)
Diagnosis
Laboratory diagnosis is made on demonstration of fourfold or greater rise in specific
antibody which can be detected. By various serological tests e.g. hemagglutination
inhibitation, complement fixation, neutralization test, ELISA or G-ELISA Virus
isolation methods such as mammalian cell culture and masquito inoculation are very
expensive and time consuming and are not routinely available. Reverse transciptase
PCR, hybridization probes for nucleic acids and immunohistochemistory are newer
techniques for diagnosis
Prevention
In the absence of effective vaccine, preventation is largery dependent on vector
control
Treatment
There is no specific antiviral therapy is only important. Antipyretics, good diet, fluid
and rest is to be taken care. Paracetamol is preferred antipyretic
Medical therapy:
Gift the O2 (2-4 liter/minute)
Plasma Volume exchange (kristaloid isotonis RL / NaCl 0,9 %)
20 ml / weight given fast (bolus in 30 minutes)
Evaluation for 30 minute, is the syok handeled
Check the vital sign every 10 minute
Write the electrolyte while the electrolyte given
XII. FOLLOW UP
20.10 S: fussy
O : CM, fussy
T : 36 ° C
P : 102x/min
R : 30x/min
Sat. O2 : 99 %
ENT : flare nose -
Pulmo : VBS +/+, Rh ±/±, Wh -/-,
dullness +/-, retraction -
Cor : BP: 83/56mmHg, regular,
shouffle (-)
Abdomen : flat, soepel, painful to
press at RUQ, BS (+)N,
H/L 4 cm BAC
Urine : -
21.10 Reported to dr. Tisna about CXR
results. Said that he will come to visit
21.45 Cough (+), pulse felt (+) -more often observation
-Transbroncho 3x1 cth
-Imunos 2x1 cth
-allowed to drink
19/02/06
07.00 Lab :
Hb : 14,2
Hct : 43
Tc : 53.000
07.16 dr. Tisna’s advice :
-repeat tests for Hb, Hct,
Tc
08.10 S: calm
O : CM
T : 36 ° C
P : 101x/min
R : 30x/min
Sat. O2 : 93 %
ENT : flare nose -
Pulmo : VBS +/+, Rh +/-, Wh -/-,
dullness +/, retraction -
Cor : BP: 108/77mmHg, regular,
shouffle (-)
Abdomen : flat, soepel, not painful to
press, BS (+)N, H/L 4 cm
BAC
Urine : +
21.00 S: calm
O : CM, moderate sickness
T : 36,7 °C
P : 85x/min
R : 36x/min
Sat. O2 : 95 %
ENT : flare nose -
Pulmo : VBS +/+, Rh +/-, Wh -/-,
dullness +/-, retraction -,
Cor : BP: 108/87mmHg, regular,
shouffle (-)
Abdomen : a little bit dome-shaped
and stiff, not painful to
press, BS (+)N, H/L 4 cm
BAC
Ext. : warm
Urine : +
Input: 1961cc
Output: 2710cc