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HISTORY
Fever was experienced by the patient since 7 days ago, fever
HISTORY (CONT)
History of disease:
IA was brought by her mother to Haji Adam Malik
General Hospital Medan complaining having high
fever. The mother explained that before coming to
Haji Adam Malik General Hospital, she took her
child to a midwife. The child was given unknown
medication from the midwife. And yet the fever has
not resolved.
HISTORY (CONT)
History of medication: unclear
History of family: RMT is the 3rd child of 4 siblings
History of parents medication: unclear
History of pregnancy: the age of the mother was
HISTORY (CONT)
History of birth:
Birth assisted by clairvoyant spontaneously. Baby was born
pervaginal and cried immediately. Bluish was not found. Body
weight, body length, and head circumference were not measured.
History of feeding:
6 months of breast feeding.
History of immunization:
not completed, only had Polio vaccine 1, BCG 1 and Measles
during the 9th month.
History of growth and development:
Her parent said that she grew normally. She was also on time to
develop talking, crawling, and walking skill.
PHYSICAL EXAMINATION
Present Status
Level of consciousness: Compos mentis
Body temperature: 38,5C.
BW: 7,4 kg, BH: 70 cm,
W/A -3<SD<-2, L/A: 92.17%, W/L: 77%,
anemic (-), cyanosis (-), dyspnea (-), fever (+),
Localized status
Head:
Eyes: Light reflex +/+, isochoric pupil, conjunctiva
palpebral inferior pale (-/-)
Ears : within normal range
Nose: within the normal range
Mouth: within the normal range, mucosa of mouth
is dry.
Neck :
Lymph node enlargement (-)
Abdomen :
Soft, non tender, normal peristaltic, liver and
spleen was not palpable
Chest X-Ray
Results: CTR of
56% , Aorta
dilatation (-),
Pulmonal artery
dilatation (-),
downward apex of
the heart,
Congestion (+),
Infiltrate (+)
Conclusion :
Cardiomegaly with
congestion
LABORATORY FINDINGS
Test
Result
Unit
Hemoglobin
10.20
g%
Reference
Range
10.7-17.1
Erythrocyte
4.14
106/mm3
3.75-4.95
Leukocyte
18.25
103/mm3
6.0-17.5
Thrombocyte
311
103/mm3
217-497
Hematocrite
29.40
38-52
Eosinophil
4.10
1-6
Basophil
0.500
0-1
Neutrophil
25.60
37-80
Lymphocyte
50.70
20-40
Monocyte
19.10
2-8
Unit
Reference Range
103/L
1.9-5.4
9.25
103/L
3.7-10.7
Absolute
count
Monocyte 3.48
103/L
0.3-0.8
Absolute
count
Basophil 0.09
103/L
0-0.1
Absolute
count
Result
Neutrophil 4.68
Absoulute
Lymphocyte count
MCV
71.00
fL
93-115
MCH
24.60
pg
29-35
MCHC
34.70
g%
28-34
Result
Unit
Reference
Range
pH
7.470
7.35-7.45
PCO2
23.0
mmHg
38-42
PO2
201.0
mmHg
85-100
Bicarbonate(HCO3)
16.7
mmol/L
22-26
Total CO2
17.4
mmol/L
19-25
Base Excess
-5.9
mmol/L
(-2)-(+2)
O2 Saturation
100.0
95-100
Electrolyte
Test
Result
Unit
Reference
Range
Calcium
8.8
mg/dL
8.4-10.8
Sodium
138
mEq/L
135-155
Potassium
3.8
mEq/L
3.6-5.5
Chloride
100
mEq/L
96-106
anisocytosis.
Leukocyte: Atypical Lymphocytes (+)
Thrombocyte: Normal
Differential Diagnosis
Typhoid Fever + Bronchopneumonia
Malaria + bronciolitis
DIAGNOSIS
Typhoid Fever + Bronchopneumonia
TREATMENT
IVFD D 5%, NaCl 0.225%, 30gtt/i (micro)
Paracetamol syrup 3 X 5cc
Inj Ceftriaxone 350 mg/12hours/IV (H1)
Filtered chicken porridge 740kkal/day with protein
14,8gr
28/10/2015
S
Fever (+),
seizure (-),
Shivering
(-),cough(+)
Diarrhea(+)
Vomit(+)
Dyspnoe(+)
dd: 1)Typhoid
Fever
2) Malaria
Plannings:
whole blood
count, blood
smear, blood
culture, photo
thorax
O2 1-2 L/i
Paracetamol syrup 3
X 5cc
.
Lab Findings
Laboratory findings:
Diftel:
Hematology
(4.40-4.48)
Eosinophil 1% (1-6)
13.5)
Ht 36.80 % (37-41)
(1,9-5,4)
450)
(3,71.7-10.7)
(0.2-0.8)
29/10/2015 30/10/2015
S
Fever(+),
cough (-),
flu
(-),
vomiting
(-),
nausea
(+),
Dyspnoe(
+)
dd: 1)Typhoid
Fever
2)Malaria
Plannings :
tubex test,CRP,
Procalcitonin,
urinalisis
Plannings:
blood culture,
photo thorax,
Blood smear
Results:
Tubex test : +
(4)
CRP : Blood smear :
plasmodium (-)
Paracetamol syrup 3
X 5cc
Inj Ceftriaxone 350
mg/12hours/IV (H1)
Filtered chicken
porridge 740kkal/day
with protein 14,8gr
31/10/2015
S
O
Fever
(-), Sensorium : compos mentis, T:37.20C
vomiting (-),
Head :
diahrea (-)
-Eye: light reflex (+/+), isochoric pupil,
A
dd:1)Typhoid
P
-
Fever
Photo thorax:
infiltration (+)
dextra lung
Conclusion:
Bronchopneum
onia
Inj ampisillin
350mg/6jam/iv
Inj gentamisin
60mg/24hour/iv
Ambroxol
3x4mg
Nebul NaCl
0,9% 5cc/8hour
IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)
01/11/2015 08/11/2015
S
Fever
(-), Sensorium : compos mentis, T:37.20C
vomiting (-),
Head :
diahrea (-)
-Eye: light reflex (+/+), isochoric pupil,
dd:1)Typhoid
IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)
Inj ampisillin
350mg/6jam/iv
Inj gentamisin
60mg/24hour/iv
Ambroxol
3x4mg
Nebul NaCl
0,9% 5cc/8hour
Filtered chicken
porridge
740kkal/day
with protein
14,8gr
Fever +
bronchopneum
onia dextra
Plannings:
waiting for
blood
09/11/2015
S
A : dd:1)Typhoid
IVFD D 5%,
NaCl 0.225%,
30gtt/i (micro)
Inj ampisillin
350mg/6jam/iv
Inj gentamisin
60mg/24hour/iv
Ambroxol
3x4mg
Nebul NaCl
0,9% 5cc/8hour
Filtered chicken
porridge
740kkal/day
with protein
14,8gr
Fever +
bronchopneumonia
dextra
Blood culture
result: bacterial
growth (-)
10/11/2015 11/11/2015
S
dd:1)Typhoid
Inj ampisillin
350mg/6jam/iv
Inj gentamisin
60mg/24hour/iv
Ambroxol 3x4mg
Filtered chicken
porridge
740kkal/day with
protein 14,8gr
Fever +
bronchopneum
onia dextra
DISCUSSION
Theory
Cases
Most patients who present to hospitals The patient in the case is 1 years and 1
with typhoid fever are children or months old.
young adults from 5 to 25 years of age
The hemoglobin level, white-cell count, The hemoglobin level, white-cell count
and platelet count are usually normal or and platelet count for this patient are in
reduced. Disseminated intravascular the normal range.
coagulation may be revealed by
laboratory tests, but it is very rarely of
clinical significance
Confirmed case of typhoid fever = A The patient had fever for 7 days,
patient with fever (38C and above) that temperature in the day of admission
has lasted for at least three days, with a 38.5C and have a positive Tubex test.
laboratory-confirmed positive culture
(blood, bone marrow, bowel fluid) of S.
typhi.
SUMMARY
IA, a 1 years 1 months old boy,
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