Typhoid Case Presentation

7/24/2019 Typhoid Case Presentation

1/17

TYPHOID FEVER

A CASE PRESENTATION

PEDIATRIC STATION OF WALEDHOSPITAL

MEDICAL FACULTY OF UNSWAGATI

CIREBON2015

CONSULTANT:Irman Permana Dr! S"!A!

CREATED ANDPRESENTED BY:

Noviana Estikasari.


2/17

Patients Identity:

Name :An. R.Age :10 years old

Sex : Male

Address : Karang Mekar

Marriage Stats :Single

Religion :Islam!ate Entering "os#ital :$%to&er '(t)*'01+


3/17

ANAMNESIS

C#$e% C&m"'a$n : ,)e #atient #resented -it) ever

H$()&r* &% Pre(en) I''ne(( :A male /)ild -as &rog)t &y )er #arents to t)e emergen%y%are nit o aled Regen%y "os#ital -it) ever* #er%eiveda&ot seven days ago. ,)e ever elt sin%e Satrday atert)e #atient %ame &a%k rom s%)ool $%to&er 12t)* '01+3.

,)e ever s4ered -as 5%tating 6 arise es#e%ially in t)ening)t and de%reases in t)e morning.

,)e Patient also %om#lained o diarr)oea* or a&ot ( times#er day. ,)e stool -as loose and -atery* -it)ot m%osand &lood. 7eside t)at* t)e #atient also %om#lained onasea and &ody -eakness.

,)e #atient -as &rog)t &y )er #arents to a nearest

#rimary )ealt) %are a%ility* &t t)e sym#toms arentim#rove -it) t)e treatment.


4/17

Pa() Me+$,a' H$()&r*,)e Patient -as never s4er rom same

%om#lain &eore

Fam$'* H$()&r*None o t)e amily mem&er )as t)e same %om#laint

or )as ever &een )os#itali8ed or t)e same%om#laint 93

S&,$a' an+ E,&n&m* H$()&r*

,)e Patient rarely eat t)e meal %ooked &y )ermot)er and #reer to %onsme n)ealty sna%ksater s%)ool.


5/17

H$()&r* &% M&)#er-( Pre.nan,* an+C#$'+/$r)#

,)e #atients mot)er: rotine %)e%k#s int)e village mid-ie "istory o illness dring #regnan%y 93 ,)e Mot)er denied any %onsm#tion o ot)er

medi%ine &t t)e s##lemental medi%ationrom t)e %)e%k#s

Per$na)a' an+ P&() na)a':

,)e #atient -as &orn s#ontaneosly* termgestational age* and t)e delivery -as )el#ed&y a mid-ie.

,)e #atient -as s#ontaneosly %ry at &irt)

H$()&r* &% M&)#er-( Pre.nan,* an+C#$'+/$r)#


6/17

eeding "istory

0 6 ; mont)s : 7reastmilk

2 mont)s : Milk Porridge< Mont)s : ,im Ri%e

= Mont)s : Porridge

1' Mont)s : Solid ood

Immunization

"e#atitis :>x

7/? :1xPolio :(x

!P, :>x

Measless @a%%ine :1x


7/17

H$()&r* &% Gr&)# an+ Dee'&"men)

A.e Gr&)# an+ Dee'&"men)

( mont)s A&le to lying on )er stoma%)

< mont)s A&le to sit do-n

1 year old A&le to -alk


8/17

P#*($,a' Eam$na)$&n

Genera' Eam$na)$&n:

Genera' A""earan,e: Moderately ill

C&n(,$&3(ne(( Lee': ll %ons%iosness E( @+M;3

4$)a' S$.n:

Hear) Ra)e : 1>'xminte

RR :'( xminte

Tem" : >=*1o/

An)#r&"&me)r*:BW: '; kg

67F$n+$n.(


9/17

L&,a' Eam$na)$&n

Hea+

E*e( : /onBn%tival Pallor 99S%leral I%ters 99

Ne,8

Dym#)adeno#at)y 99


10/17

T#&ra

In("e,)$&n

Normot)orax* symmetri%al* &ro-n skin*inter%ostal retra%tion 93* a#ex &eat is nseen

Pa'"a)$&n

,enderness 93* Normal a#ex &eat or%e*

symmetri%al ta%til remits.Per%ssion : Sonor on t)e -)ole o t)e lngeld

As%ltation : 7@S FF* )ee8e 993. R)on%)i993* Symmetri%al @o%al remits

C#&r+$( :

1stG 'nd"eart sond are reglar* no mrmr* no

gallo#.


11/17

A&domen* Extremities and Skin

A/+&men :

7ro-n skin* Sot* distention 93* E#igastri%retra%tions 93 Normal &o-el sonds E#igastri% tenderess Diver and s#leen is not #al#a&le Skin trgor reverse ra#idlyE)rem$)$e( :arm A%ro%yanosis 99 /a#illary rell time H'v Preti&ial edema 993

6 6


12/17

Re(3me:

A 10 years old male %)ild -as &rog)t to

Emergen%y /are Jnit o aled "os#ital -it) ever*#er%eived 2 days ago. ,)e ever ty#e -as remitten.Nasea and &ody -eakness are also #resent."e -as &rog)t to t)e rst )ealt %are a%ility &t

t)e sym#toms doesnt im#rove -it) t)e treatment.,)ese are t)e ndings rom #)ysi%al examination.,)e general a##earan%e -as moderately ill* t)elevel o %ons%iosness ll level o %ons%iosness

E(@+M;3."R: 1>' RR: '( ,em#: >=*1o/. 7: '; kgrom t)e a&dominal examination* e#igastri%tenderness -as ond.

E9AM!


13/17

D$eren)$a' D$a.n&($(

!enge ever

,y#)oid ever

R&3)$ne B'&&+ Te() 4a'3e

Haem&.'&/$n =**1

Er*)#r&,*)e (*'

Hema)&,r$) '=

P'a)e'e) 1;'0S. Paraty#)i A9$ L 1: >'0S. Paraty#)i 79$ L 1:>'0

S. Paraty#)i /9$ L 1: 1;0S. ty#)i " L 1:>'0S. Paraty#)i A9" L 1:1;0S. Paraty#)i 79" L 1:>'0S. Paraty#)i /9" L 1:00


16/17

T#era"*:

I@! RD > %%Kg 7ody eig)t)or

Para%etamol (x>00 mg iv

/etriaxon 'x1 gr iv

!iet %ontains liid ood* < x 1+0 %%

Pr&.n&($( :

9 o ad @itam : Ad &onam

9 o ad n%tionam : Ad &onam

9 o ad Sanationam : Ad &onam

E+3,a)$&n

7ed Rest dring ever

Diid diet dring illness


17/17

Man* T#an8(

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Typhoid Case Presentation