MORNING CASE

REPORT
June 3 , 2016
rd

Patient Identity
Name

: NMS
Sex
: Female
Age
: 47 yo
Religion
: Hindu
Address
: Denpasar
MR Number
: 16023817
Time of arrival : 03/6/2016 at 07.45
PM

Anamnesis
Chief Complain

: Fever

Present history
Patient

came from home with complaint of

sudden fever since 6 days BATH. Fever
was suddenly high and continuous.

The

temperature reduced after she took

the medicine but then her fever increased
again. Her temperature was 39,2 C.

The

temperature reduced since the day of

admission.

Anamnesis
Present history (cont)
She

also complained about nausea and

vomiting since 2 day BATH and patient has
vomitted 6 times on the day BATH.
There

was no sign of nose and gum bleeding .

Urination

and defecation was said to be

normal.
The

nose.

was no breathlessness, cough, or runny

Past illness history

No history of having the same complaint before.
History of asthma, hypertension, DM, and heart
disease was denied by the patient.

Family history
None of her family members have similar
symptoms.
Family history of asthma, diabetes mellitus,
hypertension, and heart disease was denied.

Social history
No neighbours or associates
symptoms.
Smoking (-), alcohol (-)

have

similar

Physical examination
Present status
Appearance
Consciousness
Blood pressure
Axillary Temp.
Pulse rate
Respiratory rate
Weight
Height
BMI

: Moderately ill
: E4V5M6
: 110/70 mmHg
: 38,3 OC
: 92 bpm, regular
: 20 x/min
: 65 kg
: 165 cm
: 23,8 kg/m2

Physical examination
General Status
Eyes
: Anemic -/-, icterus -/-, Pupil
Reflex (+)
ENT
: Epistaxis (-)
Mouth
: history of Gum Bleeding (-)
Neck
: 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

: symmetrical (static and dinamic)

: tactile fremitus N/N
: sonor/sonor

Physical examination
Abdomen

inspection : Distention (-)

auscultation : Normal bowel sounds
palpation
: Liver
: unpalpable
: Spleen : unpalpable
: Tenderness (-)
percussion : Tympani
Extremities

warm + + edema - + +
- -

Complete Blood Count (03/6/2016)

Parameter
WBC
-Ne

Result

Unit

Remarks

Reference range

2.73

103/L

Low

4,1 10,9

Low

47,0 80,0

Abdomen:
distensi (-)
44,04 % Insp : %

-Ly

40.46 %

Ausc :%Bowel sound (+) normal13,0 40,0

-Mo

37.20 %

High
Palp :% H/L not palpable

2,0 11,0

-Eo

0.81 %

%
tenderness(-)

0,0 5,0

-Ba

1.20 %

0,0 0,1

RBC

4.75

%
Ballotment
(-)

HGB

13.20

HCT
MCV
MCH

42.87

106/L

4,00 5,20

g/dL

12,00 16,00

Perc: Tympani (+)

%

- - edema
Extremity:
pitting
82.98
fL
- -

High

+, warm
+
+ +

36,0 46,0
80,0 100,0

27.20

pg

MCHC

30.80

g/dL

31,0 36,0

RDW

11.83

11,0 14,8

PLT

36.94

103/L

MPV

11.10

fL

Low

26,0 34,0

150 440
6,8 100,0

Assessment
Suspect DHF Grade I day VI

Treatment

Hospitalized

IVFD RL 30 dpm

Paracetamol 3x500mg (PO) (if needed)

Domperidon 3x10 mg (PO)

Mineral water intake 1,5 - 2 liters daily

Planning
Planning Diagnostic
Dengue serologic test (IgG/IgM anti
dengue) on 7th day

Monitoring
VS, Complaints
CBC @ 12 hours