A.

anamnesis
Patient identity
Name : Tn. RI
Gender : Man
Age : 16 years
Address : Katibung Lampung Regency south
admission: January 31, 2017
anamnesis conducted January 31, 2017, at 07.00, in autoanamnesis

Main complaint : Fever

Disease History Now
Patients come to the hospital with complaints of fever since 10 days of referral of the
RS Trump. Fever felt mainly late in the evening, rising slowly, sometimes with chills and
night sweats. Fever accompanied by nausea, vomiting 1 times containing food,
abdominal pain heartburn, and poor appetite. Fever is not accompanied by a cold and
cough. Patients also did not complain liquid chapter or constipation. Chapter red or
blackish denied. urinating as usual.
Patients had previously been taking medicine from health centers (paracetamol,
amoxicillin and ulcer medicine) fever is felt not reduced.

Past medical history

Never experienced a similar complaint before

Family Disease History and Environment

None had similar complaints.

B. Physical examination
General circumstances: looks ill being
Awareness : compos mentis
vital signs:
Blood pressure : 90/60 mmHg
Pulse : 78 x / min, regular, sufficient contents
RR : 20 x / min
Temperature : 36.5 C
Checking the status of a generalist:
Head : does not seem abnormalities
Eye : sunken eyes (+), conjunctival pallor (-), sclera jaundice (-)
Tongue : Tongue looked dirty
Neck : no enlarged lymph nodes
thorax : normal form.
lung
Inspection : Symmetrical, there is no motion lag.
palpation : fremitus right lung is equal to the left lung
percussion : resonant in both lung fields
auscultation : vesicular breath sounds, ronkhi (-)
 Heart
Inspection : iktus apex does not seem
palpation : iktus cordis was not palpable
percussion : heart border within normal limits
auscultation : S1, S2 single, regular, gallops (-), murmur (-)
abdomen
Inspection : flat
palpation : epigastric tenderness (+), the liver and the spleen is not
enlarged
percussion : timpani
auscultation : normal bowel sounds (6x / min)
extremity : akral warm, petechiae (-), CR <2 seconds
C. diagnosis
diagnosis : Typhoid fever
Differential diagnosis: malaria

D. Proposed investigations
- check malaria
- examination widal

Laboratory test results

(-)

E. Management
- diet soft
- IVFD RL 20 drops / minute
-Inj. Ceftriaxon 2x1gr
-Inj. ranitidine 2x1amp
- 3 x 500mg paracetamol
- Sucralfat syr 3 x 1cth

F. prognosis
Ad vitam: ad bonam
Ad functionam: ad bonam
Ad sanationam : ad dubia bonam

Typhoid fever
A. Definition and etiology
Acute systemic disease characterized acute fever due to infection with
Salmonella sp (more than 500 sp). The species is commonly known in the clinic is
Salmonella typhi, Salmonella paratyphi A, B, C
B. clinical manifestations
C. diagnosis
Diagnosis of typhoid fever can anamnesis, physical examination and
investigation. However, a definitive diagnosis can be established from blood culture
results. The results of blood cultures showed 40-60% positive in patients early in the
disease and feces and urine culture will be positive after the first week of infection.
Stool cultures are sometimes also positive in the incubation period. Laboratory tests
were performed to confirm the diagnosis of typhoid fever is not very specific. In the
complete peripheral blood tests often found leukopenia, but can also occur
leukocytosis or a normal leukocyte levels. Widal examination was also done in
helping the diagnosis of typhoid fever. Widal test is performed by measuring
antibodies against antigens O and H of Salmonella Typhi, but this test is less specific
and sensitive.