CASE REPORT

EMERGENCY ROOM
September 9th 2015
GP on duty :
Dr. Gerald Abraham
Dr. Dea Martasukma
Coass on duty :
Ahmad Vesuvio
Prithania Nurindra

Patient Recapitulation

Mrs. E (47 years old) : Lung Carcinoma

Mr. K (76 years old) : Susp. CVD
Mr. S (68 years old) : Hypertension
Mr. I (28 years old) : Susp. DHF

Patients Data

Name : Indrajaya
Sex : Male
Age : 28 years old
Occupation : Paspampres
Religion : Moslem
Marital Status : Married
Medical Record : 815110

ANAMNESIS
Autonamnesis was performed in the ER
on September 9th 2015, 22.00 PM
Chief Complaints : high fever since 4
day before admitted to the hospital.

Present Illness History :

Patient has a high fever 4 day before being
admitted to the hospital. The fever sometimes
increases and sometimes decreases. The
fever mostly increases in the morning time.
Patient took paracetamol since the first day of
the fever but wasnt relieved. 1 day before
fever patient went to Safari Park in Bogor.
Patient complained of nausea and vomited 1
hour after admission. Vomits only occurred
once. The vomits contain food and water.
Patient also complained of breathlessness
with cough since 2 days before admission and
joints pain. Cough is present with transparentcoloured sputum.

Past Illness History :

Asthma Bronchial
Patient denied having dengue fever or
typhoid fever before.
Family Illness History :
Patients child have been diagnosed
with Dengue Hemorrhagic Fever 2 days
before patient was admitted.

VITAL SIGNS

Blood Pressure : 150/100 mmHg

Heart Rate : 96 per minute, regular
Respiration Rate : 24 per minute
Body Temperature : 38,8 oC
Body Weight : 60 kg
Body Height : 171 cm
Body Mass Index : 20.76 (normoweight)
Habitus : atleticus

PHYSICAL EXAMINATION
Head : normocephal
Eye : conjuctive anemic -/sklera icteric -/ ENT : secret from nose (+) pharyng
hyperemic (+)
Mouth : dry lips (+) coated tongue (-)
Neck : JVP 5-2 cm H2O

Lungs :
I : thoraco-abdominal breath pattern
P : equal vocal fremitus in both lungs
P : sonor in all region of lungs
A : vesicular breath sound in both lungs. Wheezing
+/+ Ronchi -/Cor :
I : ictus cordis is cant be seen
P : ictus cordis is palpable
P : cors border in normal limit
A : 1st and 2nd heart sound (+)
murmur (-) gallop (-)

Abdomen
I : striae (-) caput medusae (-) deformity (-)
lesion (-)
A : bowel sound (+) in normal limit
P : hepatosplenomegali (-)
abdomen tenderness (-)
P : tympani in all abdomen region
Extrimities
Superior : oedema (-) rumple-leed (-)
deformities (-) CRT < 2 second
Inferior : oedema (-) deformities (-) CRT < 2
second

LABORATORY EXAMINATION
Hb
Ht
Eritrosit
Leukosit
Trombosit
MCV
MCH
MCHC

15.5
47
5.6
9870
200000
84
28
33

Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

LABORATORY EXAMINATION
SGOT
SGPT
Ureum
Creatinin
Blood Sugar
Na
K
Cl

20
17
25
0.9
120
139
3.8
103

LABORATORY EXAMINATION
S. Typhi O

1/160

S. Paratyphi O

Negative

S. Paratyphi BO

1/80

S. Paratyphi CO

Negative

S. Typhi H

Negative

S. Paratyphi AH

Negative

S. Paratyphi BH

1/80

S. Paratyphi CH

Negative

URINALYSIS
Color

yellow

Transparency

transparent

pH

6.0

Mass

1-0-3-0

Protein

Negative

Glucose

Negative

Billirubin

Negative

Nitrate

Negative

URINALYSIS
Keton Bodies

Negative

Urobilinogen

Negative

Eritrocyte

2-1-2

Leucocyte

3-2-3

Sylinder Bodies

Negative

Crystal Bodies

Negative

Epithel

Positive

Etc.

Negative

RESUME
Male patient, 28 years old came to the ER
with high fever since 4 day before admission.
Cough (+), joints pain (+), breathless (+)
since 2 day before admission. Patient
vomited once when he arrived in the ER.
Patient has asthma since a long time ago.
Physical examination revealed blood
pressure 150/100 mmHg, temperature 38 oC,
pharyng hyperemic (+) dry lips (+), wheezing
on both lungs, S. Typhi O 1/160, S. Paratyphi
BO 1/80, S. Paratyphi BH 1/80

Problems List

Typhoid Suspect

Typhoid Suspect

Anamnesis :
High fever since 4 day before admission. Nausea
(+) Vomits (+) Joints pain (+)
Physical Examination :
Dry lips (+) BP 150/100 mmHg. Temp 38.8
Lab Examination :
S. Typhi O 1/160. S. Paratyphi BO 1/80. S.
Paratyphi BH 1/80
Therapies : bedrest, paracetamol drip 1 vial, IVFD
RL 30 drip per minute + neurobion 5000,
chloramphenicol 4x250 mg, low fibre diet

Typhoid Suspect

Anamnesis :
High fever since 4 day before admission. Nausea
(+) Vomits (+) Joints pain (+)
Physical Examination :
Dry lips (+) BP 150/100 mmHg. Temp 38.8
Lab Examination :
S. Typhi O 1/160. S. Paratyphi BO 1/80. S.
Paratyphi BH 1/80
Therapies : bedrest, paracetamol drip 1 vial, IVFD
RL 30 drip per minute + neurobion 5000,
chloramphenicol 4x250 mg, low fibre diet