Direct by : Sri Tati Hartati

Advicer : dr. Irman, Sp.A / dr. Tatan Sp.A /

dr. Ineu, Sp.A
*Name : A
*Age : 6 y.o
*Sex : Male
*Address : Susukan Agung
Main Complain : Fever
* Patient came to the Waled Hospital escorted by her parents with fever
since 9 days. Fever is felt up and down and going on constantly. Patient
also have complaints with nausea, headache, decreased appetite,
cough and pain in the abdominal area, especially when it pressed.
Patient had not defecate for about 4 days. Patient hadn’t complain
with seizures, loss of consciousness, vomiting and bleeding.
* A history of suffering from the same disease previously does
not exist. There wasn’t a history of the same disease in the
family and neighbors. History of contact with patient with
long coughing or taking drugs for a long time does not exist.
Immunization history was complete. Age-appropriate
developmental history.aku bingung mksud kamu apa disini
* Treatment history: patient had been brought to the midwife
and doctor's clinic and was given medications. Fever
decreased when taking the drug, but re-appeared when the
drug is up.
General examination
* General appereance : Alert
* Blood pressure : 100/60 mmHg
* Pulse : 112x/minute, regual, equal
* Respiration : 24 x/minute
* Temperature : 39,4C
* Body Weight : 20 kg
* Body Height : 115 cm
* Nutrition Status
BMI/Age : < pesentil -3
Height/Age : < pesentil -3
* Body surface : 0.56
Spesifik examination
* Head : Normocephaly
* Eyes : Sclera icteric (-) Conjungtiva Anemis (-)
* Nasal : Secret (-)
* Mouth : Enlargement of tonsil (-) T1 : T1
Hiperemic pharing (+)
* Neck : Lymphadenopathy (-)
* Thorax : Symmetric with good expansion intercostal retractions (-)
- Lung : Breath sound vesicular right=left, rales (-),
wheezing (-), rhonchi (-)
- Heart : S1,S2 regular rhythm.
* Abdomen : Soft, Liver and spleen is not palpable, Bowel sound (+)
28 x/minute
* Extremities : Warm, Acrocyanosis (-) CRT <2”
* Typhoid Fever
* Dengue Fever
* Complete Blood Count
Hemoglobin : 11,8
Leukosit : 8,8
Eritrosit : 4,87
Hematokrit : 37
Trombosit : 358
Basofil :1
Eosinofil :0
Neutrofil Batang :0
Neutrofil Segmen : 56
Limfosit : 34
Monosit :9
* Tubex test : Positive
*Typhoid Fever
* IVFD NaCl 40 cc/hours
* Paracetamol syr 3x2 cth ech time fever
* Kloramfenikol 250 mg pulv 3x1
* Ceftriaxone 2x750 mg iv