DIFFERENTIAL DIAGNOSISPAGE OF VALIDATION

Case presentation
A FEMALE 45 YEARS OLD WITH DEANGUE HAEMMORAGIC FEVER GRADE II AND
MELENA CAUSSED BY NON VARICEAL BLEEDING VARICEAL BLEEDING
By:Hikaru Fujito
Accepted in the date :
14/3/2016
Supervisor
dr. Dhani Redhono H, Sp.PD KPTI
TROPICAL MEDICINE IN MEDICAL FACULTY OF
SEBELAS MARET UNIVERSITY / RSUD DR MOEWARDI
S U RAKAR TA
2016

A.PATIENT IDENTITIY
I. ANAMNESA
A. Patient Identitiy
Name : Ny. TS
No. Medical Record : 01332219
Sex: Female
Age : 45 Years old
Addres : Karanganyar
Religion : Islam
Education : Junior High School
Status : Married
Work : House Keeper
Examination date : March 9th 2016

B. The data took from

Autoanamnesis, alloanamnesis and The
examination in March 9th 2016
Chief Complaint :
Defecate black since 2 days ago

2.Disesase History:
The patient come with the symptomp, she has
defecate black since 2 days ago before she come to
hospital. It has a soft consistensy, fishy smells. She
has nausea too since 2 days ago and the she has not
a vommit. She has abdominal in the epigastric. The
pain is not continuesly. The abdominal pain
increase when she eat, it cannot decrease with the
drugs.
She has a headache since 4 days ago, the pain is
not continously and increase when the patient do
some activities and decrease when she take a rest.

She has a fever since 5 days ago, the fever is not

continously and decrease with antipiretik drugs, but
the fever not gone. The patient feel that she has not
fever since 1 days ago. She has not symptomp like the
bloddy gum, nose bleeding and purple.
The patient has a bloody spot in her extremity since
12 hours ago. She has not complain in urinary system.
Before she goes to hospital , she went to Primary
health care, and the doctor said she has a dengue
fever, and the doctor reference her to Moewardi
hospital. In the neighborhood there is some one who
get the dengue fever too.

3.The History of Disease in the Past

Disease
Diabetic

None

Heart disease

None

Hypertension

None

4.

The

Family History

Disease
Same symptomp

Not Known

Heart disease

Not Known

Diabetic

Not Known

Hypertension

Not Known

5.Daily life
Daily Life
Smoke

None

Alcohol

None

Sport

She seldom do the sport

6. Socioeconomic
The patient 45 years old and she
work as a house keeper and the
patient live with her husband and her
2 child. Patient use the health
insurance.

C.PHYSICAL EXAMINATION
Physical examination do in March 9th 2016:
1.

General state

GCS E4/V5/M6

2.

Vital Sign

Blood Pressure

: 90/70 mmHg

Heart Rate

: 80x/minuit, reguler, equal

Respiratory rate : 20 x/minuit

Temperature

VAS : 2

: 37,1 0C

3.

Skin

: brown, decrease turgor (-), dry (-) teleangiektasis (-),

petechie (+), yellow (-).

4.

Head

: Mesocephal, Temporalis muscles atrophy (-), fall down hair (-),

scar (-)

Eye

: pale conjungtiva (-), icteric sklera (-/-)

Nose

Ear

Mouth : sianotic lips (-), atrophic of tounge papil (-), bloody gum (-)

Neck

: bloody nose (-/-)

: secret (-/-), discharge (-/-)
: JVP= R + 2 cm, trachea positition in the middle, symmetric, enlarged
thyroid glans (-), enlarged limfonodi glands (-), neck stiffnes

(-).

Thorax : Normochest, Symmetric, retraction (-), enlarged limfonodi

glands (-/-), spidernevi(-), Pectoralis muscles atrophy (-)

Cor

Inspection

Ictus cordis is not visible

Palpation

Ictus Cordis palpable in SIC V linea axillaris anterior

Percussion

Upper right heart border : SIC linea parasternalis dextra

Bottom right heart border : SIC V linea parasternalis dekstra

Upper left heart border

Bottom left heart border : SIC V 2 cm linea axillaris anterior

: SIC linea parasternalis sinistra

The heart border is not widen

Aucultation : heart sound I-II normal intensity, reguler, noisy sound(-),

gallop (-)

Pulmo
a. Front

Inspection

Static

Dinamic :

Palpation

Static

Dinamic : the right chest movement = left chest movement

Percussion

Right

: Normochest, Simmetry
Retraction (-)

: Simmetry

: Faint sound in the border of pulmo-hepar in SIC

VI linea medioclavicularis dekstra,

Left : Sonor, in the border of cor-pulmo

Auscultation

Right

: Vesikular sound, additional sound : wheezing (-),

crackles (-)

Left : Vesikular sound, additional sound : wheezing (-),

crackles (-)

b.

Back

Inspection
-

Static

Dinamic : chest breath simmetry right=left, chest retraction(-)

: Normochest, simmetry

Palpation
- Static
-

: Simmetry

Dinamic : the right chest movement = left chest movement

Percussion

- Right

: Sonor

- Left

: Sonor

Auscultation
- Right

: Vesikular sound, additional sound : wheezing

(-), crackles (-)

- Left : Vesikular sound, additional sound : wheezing

(-), crackles (-)

12. Abdomen

Inspection

scar (-), striae (-), caput medusa (-)

Auscultation :

bowel sound (+) 12x/minuit

Percussion

tympani, undulation test (-), area traube timpani

Palpation

Supel, tenderness (+) in epigastric, hepar and lien

not palpable

13. Ekstremity
Petechie

Oedem

II.SUPPORTING OF EXAMINATION
Blood Laboratory in March 9th 2016
Examination

result

unit

Normal range

Hemoglobin

19.2

g/dl

13.5-17.5

Hematokrit

55

33-45

Leukosit

4.9

ribu/ul

4.500 11.800

Trombosit

18

ribu/ul

150.000-450.000

4.69

106/ul

4.5-5.9

Eritrosit

III. ASSESMENT
1. Dengue

hammerogic fever grade II

2. Melena

caused by the trombositopenia

IV. THERAPY

Bed resting

Ringer Laktat

Omeprazole injection 40 mg per 12 hours (intra venous)

sucralfat syrup 15 cc every 8 hours

paracetamol tablet

trombocyte concentrate transfution 4 kolf until the trombocyte

is up more than 100.000

30 drops per minuit

500 mg every 8 hours

V. PLANNING

Ig G/Ig M wait for the result

Check the blood laboratory for 12 hours

VI. FOLLOW UP
March 11th 2016

Patient Complaint : stomachache, pain in the muscles and joint, nausea

Physycal examination:

General state: E4V5M6

Vital sign : blood pressure 120/70

Heart rate 80x per muinuit
Respiratory rate 20 x per muinuit
Temperature 36,5C

Eye

: pale conjungtiva (-), icteric sklera (-/-)

Nose

Ear

Mouth : sianotic lips (-), atrophic of tounge papil (-), bloody gum (-)

Neck
: JVP= R + 2 cm, trachea positition in the middle, symmetric, enlarged
thyroid glans (-), enlarged limfonodi glands (-), neck stiffnes (-).

: bloody nose (-/-)

: secret (-/-), discharge (-/-)

Thorax : Normochest, Symmetric, retraction (-), enlarged limfonodi

glands (-/-), spidernevi(-), Pectoralis muscles atrophy (-)

Cor

Inspection :

Ictus cordis is not visible

Palpation

Ictus Cordis palpable in SIC V linea axillaris anterior

Percussion :

Upper right heart border

: SIC linea parasternalis dextra

Bottom right heart border : SIC V linea parasternalis dekstra

Upper left heart border

: SIC linea parasternalis sinistra

Bottom left heart border

: SIC V 2 cm linea axillaris anterior

The heart border is not widen

Aucultation : heart sound I-II normal intensity, reguler, noisy sound(-),

gallop (-)

Pulmo

Inspection

Static

Dinamic:

Palpation

Static

Dinamic: the right chest movement = left chest movement

Percussion

Right

: Normochest, Simmetry
Retraction (-)

: Simmetry

Faint sound in the border of pulmo-hepar in SIC

VI linea medioclavicularis dekstra,

Left

Auscultation

Right

Sonor, in the border of cor-pulmo

vesikular sound, additional sound : wheezing (-),
crackles (-)

Left

vesikular sound, additional sound : wheezing (-),

crackles (-)

Abdomen
Inspection

: scar (-), striae (-), caput medusa (-)

Auscultation : bowel sound (+) 10x/minuit

Percussion

:tympani, undulation test (-), area traube

timpani

Palpation

:Supel, tenderness (+) in epigastric,

hepar and lien not palpable

Ekstremity
Petechie

Oedem

Blood Laboratory in March 10th 2016

Examination

Result

unit

Normal range

Hemoglobin

18.9

g/dl

13.5-17.5

Hematokrit
Leukosit

53
6.3

%
ribu/ul

33-45
4.500 11.800

Trombosit

18

ribu/ul 150.000-450.000

Eritrosit

5.58

106/ul

4.5-5.9

IgM dengue

Positive

negative

IgG dengue

Negative

Negative

Assesment:
Dengue

Fever grade II

Melena caussed by non variceal bleeding dd

variceal bleeding

Therapy :

Bed resting

Ringer Laktat

Omeprazole injection 40 mg per 12 hours (intra venous)

sucralfat syrup 15 cc every 8 hours

paracetamol tablet

trombocyte
concentrate transfution 4 kolf until the trombocyte is up
more than 100.000

Plan

30 drops per minuit

500 mg every 8 hours

Check blood laboratory

March 11th 2016

Patient Complaint : there is not any complaint

Physycal examination:

General state: E4V5M6

Vital sign : blood pressure 110/70

Heart rate 70x per muinuit
Respiratory rate 20 x per muinuit
Temperature 36,5C

Eye

: pale conjungtiva (-), icteric sklera (-/-)

Nose

: bloody nose (-/-)

Ear

Mouth : sianotic lips (-), atrophic of tounge papil (-), bloody gum (-)

: secret (-/-), discharge (-/-)

Thorax : Normochest, Symmetric, retraction (-), enlarged limfonodi

glands (-/-), spidernevi(-), Pectoralis muscles atrophy (-)

Cor

Inspection :

Ictus cordis is not visible

Palpation

Ictus Cordis palpable in SIC V linea axillaris anterior

Percussion :

Upper right heart border

: SIC linea parasternalis dextra

Bottom right heart border : SIC V linea parasternalis dekstra

Upper left heart border

: SIC linea parasternalis sinistra

Bottom left heart border

: SIC V 2 cm linea axillaris anterior

The heart border is not widen

Aucultation : heart sound I-II normal intensity, reguler, noisy sound(-),

gallop (-)

Pulmo

Inspection
-

Static

: Normochest, Simmetry

Dinamic:Retraction (-)

Palpation
-

Static

: Simmetry

Dinamic: the right chest movement = left chest movement

Percussion
-

Right

Faint sound in the border of pulmo-hepar in SIC

VI linea medioclavicularis dekstra,

Left

Sonor, in the border of cor-pulmo

Auscultation
-

Right

vesikular sound, additional sound : wheezing (-),

crackles (-)

Left

vesikular sound, additional sound : wheezing (-),

crackles (-)

Abdomen
Inspection

: scar (-), striae (-), caput medusa (-)

Auscultation : bowel sound (+) 10x/minuit

Percussion
Palpation

:tympani, undulation test (-), area traube

timpani
:Supel, tenderness (+) in epigastric,
hepar and lien not palpable

Ekstremity
Petechie

Oedem

Assesment:
Dengue

Fever grade II

Melena caussed by non variceal bleeding dd

variceal bleeding

Therapy :

Bed resting

Ringer Laktat

Omeprazole injection 40 mg per 12 hours (intra venous)

sucralfat syrup 15 cc every 8 hours

paracetamol tablet

trombocyte
concentrate transfution 4 kolf until the trombocyte is up
more than 100.000

Plan

30 drops per minuit

500 mg every 8 hours

Check blood laboratory

March 12th 2016

Patient Complaint : there is not any complaint

Physycal examination:

General state: E4V5M6

Vital sign : blood pressure 110/70

Heart rate 70x per muinuit
Respiratory rate 20 x per muinuit
Temperature 36,5C

Eye

: pale conjungtiva (-), icteric sklera (-/-)

Nose

Ear

Mouth

Thorax : Normochest, Symmetric, retraction (-), enlarged limfonodi glands (-/-),

spidernevi(-), Pectoralis muscles atrophy (-)

: bloody nose (-/-)

: secret (-/-), discharge (-/-)
: sianotic lips (-), atrophic of tounge papil (-), bloody gum (-)

Cor

Inspection

Ictus cordis is not visible

Palpation

Ictus Cordis palpable in SIC V linea axillaris anterior

Percussion

Upper right heart border : SIC linea parasternalis dextra

Bottom right heart border : SIC V linea parasternalis dekstra

Upper left heart border

Bottom left heart border : SIC V 2 cm linea axillaris anterior

: SIC linea parasternalis sinistra

The heart border is not widen

Aucultation : heart sound I-II normal intensity, reguler, noisy sound(-),

gallop (-)

Pulmo

Inspection
-

Static

: Normochest, Simmetry

Dinamic:Retraction (-)

Palpation
-

Static

: Simmetry

Dinamic: the right chest movement = left chest movement

Percussion
-

Right

Faint sound in the border of pulmo-hepar in SIC

VI linea medioclavicularis dekstra,

Left

Sonor, in the border of cor-pulmo

Auscultation
-

Right

vesikular sound, additional sound : wheezing (-),

crackles (-)

Left

vesikular sound, additional sound : wheezing (-),

crackles (-)

Abdomen
Inspection

: scar (-), striae (-), caput medusa (-)

Auscultation : bowel sound (+) 10x/minuit

Percussion

:tympani, undulation test (-), area traube

timpani

Palpation

:Supel, tenderness (+) in epigastric,

hepar and lien not palpable

Ekstremity
Petechie

+
-

Oedem

+
+

Assesment:
Dengue

Fever grade II

Melena caussed by non variceal bleeding dd

variceal bleeding

Therapy :

Bed resting

Ringer Laktat

Omeprazole injection 40 mg per 12 hours (intra venous)

sucralfat syrup 15 cc every 8 hours

paracetamol tablet

trombocyte
concentrate transfution 4 kolf until the trombocyte is up
more than 100.000

30 drops per minuit

500 mg every 8 hours

Plan

Check blood laboratory