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Department of Internal Medicine Christian University of Indonesia

CASE REPORT
October 25th 2013

Mr. Y, 33 y.o. East Jakarta CC : fever since 1 week before admit to hospital

Saturday, 26th October 2013 , 05:03

Findings
Fever Nausea Constipation History travel from Jayapura 1 month before admit to hospital

Assessmen t
Thyfoid fever DD/ Malaria

Therapy
Pro Hospitalized Diet : soft meal IVFD : I RL/24 hours Mm/ Levofloxacin 1 x 500 mg Omeprazole 2 x 20 mg Domperridon 3 x 10 mg Paracetamol 3 x 500 mg

Planning
Px/ -Parasitology Lab for Malaria

Appearance: moderate illness, GCS : E4V5M6, BP: 110/60 mmHg, PR : 82 x/min (adequate, regular) RR : 20 x/min, T: 37,7 C Eye : pale conjunctiva -/- sclera icteric -/-, THT : normal Neck : lymph nodes not enlarged THORAX Pulmo
Insp : symmetric Pal : vf symmetric Per : symmetric, sonor sound Aus : vesicular, wheezing -/-, ronkhi -/Heart Sound S1 S2 N, murmur gallop Abdominal Insp : flat Ausc : bowel sounds + 2x/m Per : Tympani, shifting dullness Palp : Pressure Pain -, hepar and lien not palpable Extremitas : warm acral, CR<2, edema

- - -

LAB FINDING :

Hemoglobin : 12,7 g/dL Hematocrit : 39 % Leucocyte : 11.000 /uL

Subjective Data
Name Address TC CC : Mr. Y : East Jakarta : Friday, 26 oct 2013/ 05.03 : fever

Anamnesis
Main symptom : fever Additional symptom : constipation, nausea 33 y/o male patient came with chief complaints of fever since one week before admission to hospital. Fever intermitten but more severe at night. Patient has been consume paracetamol but not getting better. Patient felt nausea but no vomitting. Patient compaint that no defecation for 4 days before go to hospital. Patient has a history travel from Jayapura 1 month before admit to Hospital. Patient has a roommate that have a same fever and sign like him.

Past Medical History and Treatment -

Family History Social History


Smoking (+) , Alcohol (+)

Objective Data
LOC Appearance BP PR RR Temp EYE THORAX Heart
Ins Pal Per Ausc : : : :

: E4V5M6 ; Composmentis : moderate ill : 110/60 mmHg : 82 x/min (adequate,regular) : 20 x/min : 37,70C : hiperemic conjungtiva -/- ; icteric -/:
IC visible IC palpable RHB ICS V line Parasternal dext, LHB ICS V lin. Midclavicula sin S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO Insp Pal Perc Ausc : Chest movement symmetric : VF right and left symmetric : Sonor symmetric : Vesicular, wheezing -/-, ronkhi -/-

ABDOMEN Insp : flat Ausc : bowel sounds + 2x/m Per : Tympani, shifting dullness Palp : Pressure Pain -, hepar and lien not palpable

Objective Data
EXTREMITIE Edema (-); warm acral,crt < 2

Assessment
Thyfoid fever DD/ Malaria

Therapy
Pro Hospitalized Diet : soft meal IVFD : I RL/24 hours Mm/ Levofloxacin 1 x 500 mg Omeprazole 2 x 20 mg Domperridon 3 x 10 mg Paracetamol 3 x 500 mg

Planning
- Parasitology Lab for Malaria

Department of Internal Medicine Christian University of Indonesia

Thank You
October, 26th 2013