Case Conference

Sunday, November th
12 , 2017
dr. Labiq/dr. Hamid/dr. Nunki/ dr. Anin/ dr. Irfan
dr. Ahimsa/dr. Cempaka
dr. Izni /dr. Devi
 PATIENT ADMISSION
Melati 2
1. B, Male, 14 years old, 54 kgs with dengue hemorrhagic fever, wellnourished.
2. Y, Male, 2 years old, 10 kgs with dengue fever, undernourished
HCU Neonatus
-
NICU
-
HCU Melati 2
-
PICU
-
Wing Mawar 2:
E, Male 5 years old, 15 kgs with acute tonsilopharyngitis with low intake, mild-
moderate dehydration with vomit, wellnourished
Wing Melati 3
 IDENTITY

Name :B
Age/W/L : 14 year 10 month old/ 54 kg
/160 cm
Sex/Gender : Male
Address : Surakarta
Medical : 01398486
Record
CHIEF COMPLAINT
Fever
 CURRENT MEDICAL HISTORY

3 days 2 days 1 day EU

- Fever (sudden, high fever, persistent, parent didnt know the

temperature)
- Cough (-), cold (-), vomit (-), diarrhea (-).
- Urination and defecation were within normal
- Nosebleed (-), gum bleeding (-)
- Parent brought him to outpatient clinic given 4 medicine
(they didnt know the medicine)
 CURRENT MEDICAL HISTORY

3 days 1 day EU
- Still had fever, persistent, didnt know the temperature, just
decreased after he took the medicine
- Parent brought him to outpatient clinic, was checked the
laboratory with the result Hb 13.9 g/dl, leucocyte 3.8 g/dl,
thrombocyte 146.000/ul, Ht 46.4 %.
- Doctor suggest to hospitalization brought to doctor
Moewardi Hospital.
 CURRENT MEDICAL HISTORY

3 days 1 day ER
- Fully awake
- Fever
- Look weak
- No cough, no cold
- Last urination in the ER, yellowish colour.
- Last defecation 2 days before admission
 PAST MEDICAL HISTORY

No history of hospitalization before

8
 PAST MEDICAL HISTORY
(Family)

There was no history of fever

There was no history of dengue fever

9
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
He is the second child from two siblings of her family. Gestational age of 39
weeks and 10 days. The mother consumed vitamins and pills routinely from her
midwife. Routine check up to the midwife monthly within first and second
trimester, weekly on third trimester. There were no history of illness and
admission to the hospital during the course of pregnancy.

Delivery
The baby was delivered by a spontaneous delivery with a help from doctor in
hospital. There were no complication during procedure. The baby delivered
well, active, cried loudly. The baby weighed at 3400 grams and 49 cm in length.

Conclusion : pregnancy and delivery history were within normal limit

10
 GROWTH AND DEVELOPMENT HISTORY

Growth
According to his mother. He always gained weight and increased height when
he was taken to the nearest health center.

Development
He could interact well to his parents, his family and his friend. She also active in
his class. Now he is studying at 2nd junior high school.

Conclusion : growth and development history are within normal limit

11
 VACCINATION HISTORY

Hep B : 0 months
Polio : 1, 2, 3, months
BCG : 2 months
DPT, HepB : 2,4,6 months
Measles : 9 months
MMR : 12 months
DT, measles : 1st elementary school
TT : 3rd elementary school
MR : 2nd yunior high school

Conclusion : vaccination history was complete according to Ministry of

Healths Vaccination Schedule 1999.
12
 IX. NUTRITION HISTORY
Patient eat 3 - 4 times a day, rice with meat, fish,
vegetables. the portion of meal is same as adults
portion.

Conclusion : nutrition status is adequate

 PEDIGREE

II

III

B, 14 yo, 54
 NUTRITIONAL STATUS

BB/U : 54/51 x 100% = 105% Normoweight

TB/U : 16/164x 100 % = 94% Normoheight
BB/TB : 49/51 x 100 % = 106% Wellnourished

Conclusion : wellnourished, normoweight, normoheight (CDC 2000)

 PHYSICAL EXAMINATION

GA : moderate illness, compos mentis

VS : Heart rate: 113 bpm Temp. : 38.2oC
Resp. rate : 18 bpm
BP : 120/70 mmHg SiO2 : 98%

Head : Mesocephal
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, pupil isocor
2mm/2mm
Nose : Nostrils Flare (-) nasal discharge (-)
Mouth : Wetness (+), cyanosis (-), tonsil T1-T1 hyperemic (-),
redness of the pharyx (-)
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
 PHYSICAL EXAMINATION
Cor : I : Ictus cordis looked at SIC V LMCS
P : Ictus cordis was palpable at SIC V
P : heart enlargement (-)
A : heart sounds I-II regullary
Pulmo: I : right hemithorax = left hemithorax
P: fremitus sounds right = left
P: sonor / sonor
A: vesicular breath sounds /+ , patologic sounds -/-
Abd : I : abdominal wall // chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : liver and spleen were not palpable
Extremity: no oedema, Dorsalis pedis artery: good, Capillary refill
time< 2second
 LABORATORY RESULTS (12/11/17) 1.35 PM
Hb = 14.8 g/dl
Hct = 42 %
Leucocyte count = 3600/ul
Trombocyte count = 116.000/ul
Erythrocytes = 4.78 million/ul
MCV = 88.8/um
MCH = 31 pg
MCHC = 34.9 g/dL
RDW = 10.9 %
MPV = 8.5FL
PDW = 17 %
Eoshinophile = 0.30%
Basophil = 0.40%
Monocyte = 32.50%
Netrophil = 59.50%
Limfocyte = 32.50%
Blood glucose = 100 mg/dl

Conclusion : leucophenia, thrombocytopenia

 RLD

right pleural effusion with pleural effusion index 11%

 List of PROBLEMS

A boy, 14 years, 54kg, with :

1. Sudden, Persistent high fever, only decreased after he took the
medicine
2. No nosebleed, no gum bleeding
3. No vomit
4. Vesicular breath sound decreased in right lung
5. Laboratory : leucophenia and thrombocytopenia
6. RLD : right pleural effusion
 DIFFERENTIAL DIAGNOSIS

1. Dengue fever dd/ Dengue hemorrhagic fever

 WORKING DIAGNOSIS

1. Dengue hemorrhagic fever

2. Wellnourished
 THERAPY

1. Diet : rice 2000 kcal/days

2. IVFD Asering 3000 ml/day 125 ml/hour
3. Paracetamol (15 mg/kgBW/6 hours) 500mg/6 hours
 PLAN

1. Complete blood count/12hours

2. Urinalysis
3. Stool analysis

MONITORING

General Appearance/Vital Signs / Hydration status/8

hours
Fluid balance and Diuresis / 8 hours
 FOLLOW UP 13TH NOVEMBER 2017

S : fever (+), vomit (-)

GA : moderate illness, compos mentis
VS : Heart rate: 113 bpm Temp. : 38.2oC
Resp. rate : 18 bpm
BP : 120/70 mmHg SiO2 : 98%

Head : Mesocephal
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, pupil isocor
2mm/2mm
Nose : Nostrils Flare (-) nasal discharge (-)
Mouth : Wetness (+), cyanosis (-), tonsil T1-T1 hyperemic (-),
redness of the pharyx (-)
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
 PHYSICAL EXAMINATION
Cor : I : Ictus cordis looked at SIC V LMCS
P : Ictus cordis was palpable at SIC V
P : heart enlargement (-)
A : heart sounds I-II regullary
Pulmo: I : right hemithorax = left hemithorax
P: fremitus sounds right = left
P: sonor / sonor
A: vesicular breath sounds /+, patologic sounds -/-
Abd : I : abdominal wall // chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : Hepar and spleen were not palpable
Extremity: no oedema, Dorsalis pedis artery: good, Capillary refill
time< 2second
 WORKING DIAGNOSIS

1. Dengue hemorrhagic fever

2. Wellnourished
 THERAPY

1. Diet : rice 2000 kcal/days

2. IVFD Asering 3000 ml/day 125 ml/hour
3. Paracetamol (15 mg/kgBW/6 hours) 500mg/6 hours
 PLAN

1. Urinalysis
2. Stool analysis
3. Complete blood count/12hours
4. IgG IgM dengue in 5th day of fever

MONITORING

General Appearance/Vital Signs / Hydration status/8

hours
Fluid balance and Diuresis / 8 hours
 Clinical question: what is the benefit of daily
monitoring platelet counts for dengue patients?

P : children with dengue

I : daily platelet counts
C:
O : risk of DSS
 Validity
Was the defined representative sample of patients
assembled at a common (usually early) point in the
course of their disease)? YES.

The analysis population comprised all children aged

5-15 years with laboratory-confirmed dengue
enrolled between days 14 of illness.
 Validity
Was patient follow up sufficiently long and
complete? YES.

Length of follow up was long enough to detect the

outcome of interest, that is risk of DSS. Which occurs
most frequently on day 5 or 6 of illness.
 Validity
Were outcome criteria either objective or applied in
a blind fashion?

The Methods section provide a clear definition of

outcome .
Importancy
Importancy
 Applicability
Can I apply this valid, important evidence about
prognosis to my patient? YES

This evidence make a clinically important impact on

my conclusions about what to offer to tell my
patients.
 Conclusions
Valid, important, applicable.
Level of evidence 2b.
40
 INFEKSI DENGUE

Virus arthropod-
borne nyamuk
Aedes aegypti

Infeksi
DENV-1
Dengue
DENV-2 Famili
DENV-3 flaviviridae
DENV-4

(Halstead, 2011)41
 Secondary
heterologous
Antibody
infection
dependent
enhance-
ment
Virulensi
kuman

PATOFISIOLOGI
(Soedarmo, 2011) 42
(Suvatte, 1978)

43
KLASIFIKASI WHO 2011

(WHO, 2011)
44
KLASIFIKASI WHO 2009

(WHO, 2009) 45
MUNCULNYA IgM DAN IgG PADA PASIEN
YANG TERINFEKSI VIRUS DENGUE
INTERPRETASI HASIL PEMERIKSAAN
IgM dan IgG
IgM IgG Interpretasi
(+) (-) Infeksi primer
(+) (+) Infeksi sekunder
(-) (+) Tersangka infeksi
sekunder

(-) (-) Tidak ada infeksi

 PEMERIKSAAN RADIOLOGI
PADA FOTO THORAKS RLD

Ditemukan adanya efusi pleura terutama

disebelah hemotoraks kanan
SINDROM SYOK DENGUE

(WHO, 2011) 50
 SINDROM SYOK DENGUE
CVP meningkat, kardiomegali, kontraktilitas
jantung jelek INOTROPIK
Perdarahan masif TRANSFUSI DARAH
Transfusi darah 10 ml/kgBB fresh WB atau
5 ml/kgBB fresh PRC
Transfusi TC, FFP, kriopresipitat tidak
dianjurkan overload cairan

(WHO, 2011) 51
MONITORING LABORATORIUM PADA PASIEN
YANG DIBERIKAN TERAPI CAIRAN DAN TANPA
PERBAIKAN KLINIS

(WHO, 2011)52