By:Fuad Zainani, S.KedFamelia, S.Ked

Advisor:dr. Yulia Iriani, SpA(K)

Identification

Name : Ch. MAge : 3 yearsSex : GirlWeight : 10.3 kgHeight : 69 cmReligion : MoslemAddress : Palembang Nationality : IndonesianDoA : October 14th 2009

Anamnesis (alloanamnesis)

History of illness

Since ± 6 days before admission, the patient complained about developing high fever, the temperature increased gradually and continuously, no seizure, no shivering, no coughing, no nose secretes.

She also complained about sore throat, rhagadens, and stomatitis.

She also developed nauseas and stomachache, no vomits, no headache, no myalgias and arthralgias, no retroorbita pain.

Cont’

She also developed no nosebleeding, no gumbbleeding, and no red spots on the skin.

She had no complaint about urinations and defecations, no pain when urinating.

She got paracetamol syrup then fever decreased but increased again then.

Cont’

± 3 days before admission, the patient was still developing high fever, continuously, no seizure, no shivering, no coughing and nose secretes, there were sore throat, rhagadens, stomachache, nauseas, and no vomits.

There was no complaint about defecation and urination. Then the patient was referred to primary care center and got pulvis and amoxicillin 3x a day but her complaints were not relieved

Cont’

± 1 day before admission, the patient was still developing high fever continuously, no seizure, no shivering, no coughs, no nose secretes. There were nauseas, stomachache, no vomits.

She felt sore throat worsened and lose her appetite then weakened her body. There was rhagadens, no nosebleeding and gumbbleeding, no headache, no myalgias and arthralgias, and no retroorbita pain. There were red spots on the stomach skin which was faded by pressure.

Cont’

Then she was reffered to Emergency Room at Mohammad Hoesin Center Public Hospital and got blood laboratory examinations (The result were: Hb=11.9, Ht=35%, leukocyte counts=9,700, different leukocyte counts=0/0/2/79/13/6, thrombocyte counts=180,000). She was also tested by torniquet to provoke red spots of bleeding, the result was negative. She was suggested to continue her medication at home then come to hospital the next day to reexamine her blood.

Cont’

The result were: Hb=1.9, Ht=39%, leukocyte counts=10,000, different leukocyte counts=0/3/0/77/20/0, thrombocyte counts=172,000.

Due to her complaints were not relieved yet, then she was hospitalized at Mohammad Hoesin Center Public Hospital.

History of Past illness

History of suffering from same complaints before was denied

History of developing typhoid fever before was denied

History of developing dengue fever before was denied

History of family illness There are no patient’s family who

have the same complaints

Social and Economic Status Patient is first daughter Her father (26 years old) had

graduated from D1, nowadays works as merchantman

Her mother (24 years old) had graduated from senior high school and is fully housewife.

History of Pregnancy and DeliveryGPA : P1A0

Birth age : aterm Partus : spontaneousHelped by : midwifeBirth weight : 2,100 grBirth height : no dataCondition onbirth : cry spontaneously

History of Feeding

0 – 6 months old : breastfeed 6 – 8 months old : milk porridge 8 months old untill now : rice

History of Growth and Development Lying flat on stomach : starting at 4 months

old Crawling : starting at 7

months old Standing : starting at 10

months old Walking : starting at 12

months old

Interpretation : Motoric development within normal limit

History of Immunization

BCG : (+) scar is present DPT I, II, III : (+) Polio I, II, III, IV : (+) Hepatitis I, II, III : (+) Campak : (+)

Interpretation : Immunization was complete.

Physical Examination

General Condition Conciousness : compos mentis Pulse rate: 122 x/m, regular,

adequate tension RR : 24 x/m Temperature : 39.20 C Weight : 10.3 kg Height : 69 cm

Cont’

There’s no anemic, cyanotic, icteric and edema.

Nutritional status :W/A : 10.3/14 x 100% = 73,57%H/A : 69/96 x 100% = 71,88%W/H : 10.3/14.5 x 100% = 71,03%Based on WHO 2000, W/A -SD-< -SD Interpretation: malnutrition grade II

Cont’

Skin : Brown like sapodilla skin Head Shape : symmetric, normocephaly Hair : black, straight, pull test normal Eyes : sunken (-), anemic of palpebral

conjunctiva ,

sclera icteric (-), pupil round, isocore ø 3

mm, light reflex +/+, palpebral edema (-)

(-) tears (+),

Cont’

Nose : normal shape, secrete (-) Ears : secrete (-), normal shape Mouth : Dry lips (+), typhoid

tongue(-) Throat : Pharyngeal hyperemia (+), hyperemic tonsil (T1-T1) Neck : JVP normal, lymph node

normal

Cont’

ThoraxLung Inspection : Statically & dynamically

Symmetric, retraction -/- Palpation : Right & left stemphremitus

equal Percussion : Sonor on both lungs surface Auscultation : Vesicular (+) normal, rales

(-), wheezing (-)

Cont’Heart Inspection : ictus cordis is not

seen Palpation : thrill is not palpable Auscultation : HR: 122 x/m, regular,

HS I-II are normal, murmur (-), gallop (-)

Cont’

Abdomen Inspection : flat Palpation : soft, liver and spleen are

not palpable, pinch on abdomen skin is fast retightened

Percusion : tympani Auscultation : bowel sound (+)

normal

Cont’

Thigh fold and genitaliaLymph glands are not palpable

Extremities Cold acral (-) Cyanotic (-) Edema (-) Petechiae (+), Rumple Leed (-)

Cont’

Examination Right Leg Left Leg Right Arm Left Arm

Motion Wide Wide Wide Wide

Strength 5 5 5 5

Tonus Eutoni Eutoni Eutoni Eutoni

Clonus - -

Physiological

Reflect

(+) normal (+) normal (+) normal (+) normal

Pathological

Reflect

- - - -

Neurologic Examination

Cont’

Sensoric function : within normal limits

Nervi craniales : within normal limits

Meningeal excited symptom : none

Laboratory findingOctober 15th 2009Hematology Hb : 11,3 g/dl Ht : 34 vol% Leukocyte counts : 6200/mm3

Diff. Leukocyte counts : 0/0/0/41/59/0 ESR : 6 mm/hour Thrombocyte counts :

347,000/mm3

Blood Sugar Level : 97 mg/dl

Potassium level : 4.2 mmol/l

Diagnosis Acute tonsillopharyngitis +

malnutrition grade II

Different DiagnosesTyphoid fever + malnutrition grade II Dengue fever + malnutrition grade II

Treatment

Supportive therapy Bed rest Refined porridge dietMedication therapy Amoxicillin 3 x 150 mg Paracetamol 3 x 125 mg

Planning

Additional laboratory finding from blood, urine, and stool

Gall culture WIDAL test (at the end of fever

within first week)

Prognosis

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam

Case analysis

Cont’

Cont’

Nutritional status :W/A : 10.3/14 x 100% = 73,57%H/A : 69/96 x 100% = 71,88%W/H : 10.3/14.5 x 100% = 71,03%Based on WHO 2000, W/A -SD-< -SD

Interpretation : malnutrition grade II