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CASE REPORT
TYPHOID FEVER
and
DHF GRADE I
Fathia Rachmatina
030.08.099
Patient’s Identity
•Mr. IName
•20 Years oldAge
•Purwasari, Karawang Address
•LaborJob
•Senior High SchoolLast education
•SingleMarital status
•MoslemReligion
•SundaneseEthnic
ANAMNESE
Autoanamnese on
November,17th 2012 at 13.30
1. Chief Complaint
• fever since 5 days before hospitalized
2. Additional Complaint• Bitter taste in mouth and decreased appetite
• Abdominal pain at epigastrium region• Nausea• Fatigue and malaise • Sweating at night
3. History of Present Disease
• Mr. I, 20 years old,came to emergency department of RSUD Karawang after experiencing fever since 5 days before admitted to the hospital. The temperature of the body is increasing every day. He felt that high fever with shivered during the afternoon and the fever disappeared in the morning but never goes down to normal. Sweating at night is marked.
• Patient also complains abdominal pain at epigastric region, feels nausea, but no vomiting, bitter taste in mouth and decreased appetite. Because the lost of appetite, he feels his body weaken.
• Defecation was normal. Urination was normal
4. HISTORY OF PAST DISEASE
Same Symptoms
(2011)
Hypertension (-)
Asthma (-)
Allergy (-)
Liver disease (-)
Kidney disease (-)
Maag (+)Diabetes
mellitus (-)
5 • Same illness (-)• Heart disease(-)• Asthma (-)• Hypertension (+)• DM (-)• Allergy (-)
5. Family History
• Alcohol consumption (-)• Smoking (-)• Routine Excercise (-)• Tattoos (-)• Blood Transfusion (-)• Injected drugs (-)• Traditional beverages (-)
6. Habit
History
PHYSICAL EXAMINATIONNovember,17th 2012
at 13.30
General Condition
Appereance : Moderate ill
• Weight : 90 kgs• Height : 170 cms• BMI : 31,1
Conciusness : Compos Mentis
Nutrition : Normal
Antropometry
Vital Sign
Blood Pressure : 110/70 mmHg
• Normal
Temperature : 38 oc
• Increase
Respiration Rate : 24x/ minute
• Increase
Heart Rate : 72x/ minute
• Normal
• Normocephali, black hair, distributing evenly, not fall easilyHead
• Anemic conjunctiva -/-, • Icteric sclera -/- • Pupil isocor• Light reflex direct/indirect +/+• Palpebra edema -/-
Eyes• Lip: cyanosis(-) pallor (-)• Tongue: Coated Tongue with
hyperemic edge• Pharynx: hyperemic (-),
symmetrical, uvula at midline• Tonsil T1-T1
Mouth
• Normotia• Secret -/-• Cerumen +/+Ears
• Septum deviation (-), hyperemic mucous (-)Nose
• Lymph gland & Thyroid gland is not palpable
• JVP 5+1Neck
Thoracal Examination-Heart
InspectionIctus cordis is invisible
PALPATION• Ictus cordis is palpable at 5th ICS LMCS
PERCUSSION• Right heart border : ICS III-IV LSD• Left heart border : ICS V 1 cm medial LMCS• Upper heart border : ICS III LPSS
AUSCULTATIONReguler I-II absence of murmurs and gallop in heart’s sound
Thoracal Examination-Lung
INSPECTIONSymmetrical in shape, spider navi -
PALPATION• Equal vocal fremitus
PERCUSSION• Sonor in both lungs
AUSCULTATIONVesicular breathing sound in both lungsronchi -/- wheezing -/-
Abdominal Examination
INSPECTIONFlat, symmetrical, distended abdomen (-), icteric (-), ptechiae (-)
PALPATION• Defense muscular (-) Pain on palpation at
Epigastric, No enlargement of liver and spleen
PERCUSSION• Timpanic sound in abdomen, pain on
percution (-)
AUSCULTATIONBowel sound +, arterial bruit -, Venous hum -
EXTREMITIY
+ +
+ +
Warm acrals
- -
- -
Oedem
+RUMPLE LEED
LABORATORY EXAMINATION
November 15th 2012RESULT Normal Range
Hemoglobin 16,5 (12 – 17) g%
Leucocytes 4.300 (5.000 – 10.000)/μL
Thrombocytes 57.000 (150.000 – 450.000)/μL
Ht 45 (37 – 43) %
Differential Count
• Basophil 0 (0 – 1) %
• Eosinophil 0 (1 – 3) %
• Rod Neutrophil 0 (2 – 6) %
• Segment Neutrophil 52 (50 – 70) %
LABORATORY EXAMINATION
RESULT Normal Range
• Lymphocyte 35 (20 – 40) %
• Monocyte 13 (2 – 8) %
Random Blood Glucose 101 (80 – 140) mg/dl
Ureum 34,4 (10 – 45) mg/dl
Creatinine 1,27 (0,4 – 1,5) mg/dl
LABORATORY EXAMINATION
November 16th 2012RESULT Normal Range
Hemoglobin 15,6 (12 – 17) g%
Leucocytes 5.600 (5.000 – 10.000)/μL
Thrombocytes 34.000 (150.000 – 450.000)/μL
Ht 44 (37 – 43) %
Widal
•Salmonella Thyposa -
•Salmonella Paratyphi AO -
•Salmonella Paratyphi AH -
•Salmonella Paratyphi BO 1/80 (+)
LABORATORY EXAMINATION
RESULT Normal Range
• Salmonella Paratyphi BH 1/160 (+)
• Salmonella Paratyphi CO
-
• Salmonella Paratyphi CH
-
Anti Dengue IgG Negatif (-)
Anti Dengue IgM Negatif (-)
Resume
ANAMNESIS• ♂, 20 yo, fever since 5
days before admitted to the hospital. the temperature is increasing every day. ↑ at afternoon, ↓ in the morning, but never goes normal. Sweating at night, abdominal pain at epigastric region, feels nausea, bitter taste in mouth and decreased appetite Patient denied cough, abdominal pain and any spontaneous bleeding.
PE• Blood Pressure: 110/70
mmHg• Respiration Rate:
24X/minute• Pulse Rate: 72x/minute,
weak pulse• Temperature: 38 °C• Tongue: Coated Tongue
with hyperemic edge• Pain on palpation at
Epigastric• Rumple Leed: +
LAB• Trombocyte 34.000/μL• Ht 44%• Widal S. typhi BO 1/80
dan S. paratyphi BH 1/160.
Differential Diagnosis
Typhoid Fever
DHF Grade I
Measles
Malaria
Acute Hepatitis Virus
Working Diagnosis
TYPHOID FEVER and
DHF GRADE I
Suggested Examination
1. Blood culture
2. Widal test
3. NS 1
4. Anti Dengue IgG dan IgM
5. HBsAg and anti HBsAg
6. SGOT/SGPT
7. Radiology: Thorax
Treatment (Medicamentosa)
• IVFD RL 20 d.p.m• Ceftriaxone 2 gr 1x1 inj• Omeprazole 1x1 inj• Sanmol 3x1 tab• Sohobion 1x1 tab• Kalnex 3x1 tab• Cholescor 3x1 caps
• IVFD RL 20 d.p.m• Ceftriaxone 2 gr 1x1 inj• Omeprazole 1x1 inj• Sanmol 3x1 tab• Sohobion 1x1 tab• Kalnex 3x1 tab• Cholescor 3x1 caps
Treatment (Non Medicamentosa)
Bed RestGood
Nutrition
Prognosis
Ad vitam: ad bonam
Ad Fungsionam : ad bonam
Ad Sanationam : Dubia ad bonam
THANK YOU
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