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