m

 


 
  
 


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

Advisor:
dr. Yulia Iriani, SpA(K)
Identification

Name : Ch. M
Age : 3 years
Sex : Girl
Weight : 10.3 kg
Height : 69 cm
Religion : Moslem
Address : Palembang
Nationality : Indonesian
DoA : October 14th 2009
Anamnesis (alloanamnesis)
History of illness

ÿ 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.
ÿ She also complained about sore throat,
rhagadens, and stomatitis.
ÿ She also developed nauseas and
stomachache, no vomits, no headache, no
myalgias and arthralgias, no retroorbita pain.
 ContŨ

ÿ She also developed no nosebleeding, no

gumbbleeding, and no red spots on the skin.
ÿ She had no complaint about urinations and
defecations, no pain when urinating.
ÿ She got paracetamol syrup then fever
decreased but increased again then.
 ContŨ

ÿ ± 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.
ÿ 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
 ContŨ

ÿ ± 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.
ÿ 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.
 ContŨ
ÿ 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.
 ContŨ

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

ÿ History of suffering from same complaints

before was denied
ÿ History of developing typhoid fever before
was denied
ÿ History of developing dengue fever before
was denied
History of family illness

ÿ There are no patientǯs family who have the

same complaints
Social and Economic Status

ÿ Patient is first daughter

ÿ Her father (26 years old) had graduated from
D1, nowadays works as merchantman
ÿ Her mother (24 years old) had graduated
from senior high school and is fully
housewife.
History of Pregnancy and
Delivery
VPA : P1A0
Birth age : aterm
Partus : spontaneous
Helped by : midwife
Birth weight : 2,100 gr
Birth height : no data
Condition on
birth : cry spontaneously
History of Feeding

ÿ 0 Ȃ 6 months old : breastfeed

ÿ 6 Ȃ 8 months old : milk porridge
ÿ 8 months old untill now : rice
History of Growth and
Development
ÿ Yying flat on stomach : starting at 4 months old
ÿ Crawling : starting at 7 months old
ÿ Standing : starting at 10 months old
ÿ Walking : starting at 12 months old

ÿ Interpretation : Motoric development within

normal limit
History of Immunization

ÿ BCV : (+) scar is present

ÿ DPT I, II, III : (+)
ÿ Polio I, II, III, IV : (+)
ÿ Hepatitis I, II, III : (+)
ÿ Campak : (+)

Interpretation : Immunization was complete.

Physical Examination

Veneral Condition
ÿ Conciousness : compos mentis
ÿ Pulse rate: 122 x/m, regular, adequate tension
ÿ RR : 24 x/m
ÿ Temperature : 39.20 C
ÿ Weight : 10.3 kg
ÿ Height : 69 cm
 ContŨ

Thereǯs no anemic, cyanotic, icteric and edema.

Õ tritional stat s :
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



 : malnutrition grade II
 ContŨ

6 in : Brown like sapodilla skin

pead
Ë Shape : symmetric, normocephaly
ËHair: black, straight, pull test normal
ËEyes : sunken (†), anemic of palpebral conjunctiva ,
sclera icteric (†), pupil round, isocore ø 3
mm, light reflex +/+, palpebral edema (†)

Ë(†) tears (+),

 ContŨ

ÿ Õose : normal shape, secrete (†)

ÿ Ears : secrete (†), normal shape
ÿ Mouth : Dry lips (+), typhoid tongue(†)
ÿ Throat : Pharyngeal hyperemia (+),
hyperemic tonsil (T1†T1)
ÿ Õeck : JVP normal, lymph node normal
 ContŨ

Ú orax
Yung
ÿ Inspection : Statically & dynamically
Symmetric, retraction †/†
ÿ Palpation : Right & left stemphremitus equal
ÿ Percussion : Sonor on both lungs surface
ÿ Auscultation : Vesicular (+) normal, rales (†),
wheezing (†)
 ContŨ
peart
ÿ Inspection : ictus cordis is not seen
ÿ Palpation : thrill is not palpable
ÿ Auscultation : HR: 122 x/m, regular, HS I†II
are normal, murmur (†), gallop (†)
 ContŨ

 domen
ÿ Inspection : flat
ÿ Palpation : soft, liver and spleen are
not palpable, pinch on
abdomen skin is fast
retightened
ÿ Percusion : tympani
ÿ Auscultation : bowel sound (+) normal
 ContŨ

Ú ig fold and genitalia

Yymph glands are not palpable

Mxtremities
ÿ Cold acral (†)
ÿ Cyanotic (†)
ÿ Edema (†)
ÿ Petechiae (+), Rumple Yeed (†)
 ContŨ
ÿ Õeurologic Examination

M

  


   
 

 
 
 
 


6    

    



 

 
 
 
 


 


 ContŨ

ÿ Sensoric function : within normal limits

ÿ Õervi craniales : within normal limits
ÿ Meningeal excited symptom : none
 Yaboratory finding
October 15th 2009
pematology
Ë Hb : 11,3 g/dl
Ë Ht : 34 vol%
Ë Yeukocyte counts : 6200/mm3
Ë Diff. Yeukocyte counts : 0/0/0/41/59/0
Ë ESR : 6 mm/hour
Ë Thrombocyte counts : 347,000/mm3
ËBlood Sugar Yevel : 97 mg/dl
ËPotassium level : 4.2 mmol/l
Diagnosis
ÿ Acute tonsillopharyngitis + malnutrition
grade II

Different Diagnoses
Typhoid fever + malnutrition grade II
Dengue fever + malnutrition grade II
Úreatment

Supportive therapy
ÿ Bed rest
ÿ Refined porridge diet
Medication therapy
ÿ Amoxicillin 3 x 150 mg
ÿ Paracetamol 3 x 125 mg
Planning

ÿ Additional laboratory finding from blood,

urine, and stool
ÿ Vall culture
ÿ WIDAY test (at the end of fever within first
week)
Prognosis

ÿ Auo ad vitam : dubia ad bonam

ÿ Auo ad functionam : dubia ad bonam
Case analysis
Child girl, 3 years, addmited to the MHCPH
C ief complaint : dditional complaint:
Developing High Fever Sore throat, stomachache, nauseas

From istory of illness:

Thereǯre high fever, and sore throat

›irection to diagnose: ac te p aryngitis, typ oid fever

 ContŨ

Physical examination:
1. Hyperemic pharynx
2. Hyperemic tonsils

Acute
Tonsilloph
aryngitis
 ContŨ

Õ tritional stat s :
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




 : malnutrition grade II