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CHAPTER IV
DISCUSSION
Patient with intial D, 9 year and 1 month boy is presented with a diagnose
of DHF without shock + Expanded Dengue Syndrome. According to the previous
epidemiological study dengue is widespread throughout the tropics, with local
variations in risk influenced by rainfall, temperature and unplanned rapid
urbanization. Medan is one of the areas considered endemic in the province of
North Sumatra with 1270 dengue cases reported in 2013.
Moreover, this patient had the same clinical findings as DHF clinical
findings. Clinical findings that can be found in a DHF case are a 2-7 day illness
with high fever headache, retro-orbital pain, myalgia, arthralgia/ bone pain, rash
and haemorrhagic manifestations example positive tourniquet test, or petechial,
with evidence of plasma leakage. There are some criteria that need to be include
for us to diagnose a patient with DHF. Example, high fever or recent history of
acute fever, haemorrhagic manifestations, thrombocytopenia of 100,000
cell/mm, objective evidence of leaky capillaries.2
Patient D had fever for 7 days which is a sudden continuous high fever,
headache and joint pain found this 1 week and had spontaneous bleeding from the
nose before admitting to hospital. Patients chief complaint is hematemesis.
Thrombocytopenia also found on this patient with the value of just 28.000. But
there is no seizure or shock is found on this patient. Odem is also found on this
patients below extremities. Patient also suffered from increased breathing rate
and felt limp. This maybe because of infection in lungs or edema. So these
scenarios concludes on enforcing the diagnose of DHF without shock on this
patient.
These clinical manifestations shall become more severe during the day 3-5
where it can lead to shock. If the shock previously not treated properly it will
follow the next symptom is bleeding from the gastrointestinal tract. GI bleeding
can be mild or severe depending on how long the shock occur until treated
30
appropriately. Decreased levels of oxygen in the blood will lead to bleeding, the
lower the oxygen levels in the blood, the more severe the bleeding that occurs. At
the beginning of GI bleeding is not visible from the outside, therefore occurs in
the stomach. It will look just stomach increasingly bulge and pain when touched.
Later on, there will be vomiting blood and dysentery or black stools. 4,5 According
to this case report, this patient had these severe clinical manifestations such as
hematemesis and melena.