CASE REPORT

Identity
Name : An. J Mother’s name : Mrs. S
Sex: male Age : 35 years
Age : 5 yr 5 month Occupation : house wife
Religion : Christian Education : High school
Address : Jl. Kramat Jati
No.33 Father’s name : Tn. T
Age : 34 years
Occupation : businessman
Education : high school
 Anamnesis
Main complaints : swollen face and both
legs
Additional complaints : fever and red urine
 Anamnesis
History of present illness:
• Patient came to RS PGI Cikini with main complaints are
swollen face and both legs 2 days before admissions.
He felt the swelling is the morning after he woke up
and will be gone in the afternoon. Also, the swelling
appeared suddenly. At first, his mother thought he is
allergic to something. Other than that, patient also
complaint of fever and red urine 5 days before
admissions. His mother also said that his urine is less
than before. About 2 weeks ago, patient caught flu and
sore throat. He has not got any medication about the
swelling and other complains. He never experienced
any of these complains before.
Past Medical History
• -
Family Medical History
• -
Pregnancy history
• Antenatal care is regular, born at term,
spontaneous pervaginam, spontaneous crying,
Birth weight: 3500gr, birth length: 47cm.
Immunization History
Vaccine Basic Booster

BCG Born

DPT/DT 2nd month 4th month 6th month

Polio Birth 2nd month 4th month 6th month

Measles 9th month

Hepatitis Birth 1st month 6th month

B
MMR

TIPA
 General Examinations
• General condition : Look mildly sick
• Consciousness : Compos mentis
• Pulse : 84x/minute (regular,
strong lift, ample content
• Respiratory rate : 23x/minute
• Temperature : 37.6oC (axilla)
• Blood pressure : 110/70 mmHg
• Tinggi Badan : 74 cm
• BB : 9.4 kg
 Status Gizi
• Length/height-for-age-boys : < (-3) SD
• Weight-for-age boys : (-2) – (0) SD
• BMI-for-age-boys :
9.4kg/(0.74)2 = 17.16  (1) – (0) SD
Head
• Normocephali (Head Circumference: 53 cm), anterior fontalle close
EyeB
• mata cekung (-/-), konjungtiva pucat (-/-) sklera ikterik (-/-), pupil isokor
(2mm/2mm), reflek cahaya (+/+)
• Telinga: Bentuk normal, simetris, liang lapang, serumen (-/-)
• Hidung: Bentuk normal, cavum nasi lapang. septum deviasi (-), pernafasan cuping
hidung (-), sekret (-)
• Mulut: mukosa bibir lembab, sianosis circumoral (-), lidah tidak kotor/coated
tounge (-), faring tidak hiperemis, tonsil (T1-T1) tenang, eksudat (-)

Leher
• Bentuk: simetris
• KGB: (submandibula, preauricula, retroauricula, regio colli anterior, regio colli
posterior, supraclavicula, infraclavicula) tidak teraba membesar
• JVP: tidak dilakukan
Thoraks
• Inspeksi: bentuk simetris, diameter AP > Lateral, retraksi
intercostal (-)
Anterior Posterior
Kiri Kanan Kiri Kanan
Inspeksi Pergerakan Pergerakan Pergerakan Pergerakan
pernapasan pernapasan pernapasan pernapasan
simetris simetris simetris simetris

Palpasi Stem Fremitus + Stem Fremitus + Stem Fremitus + Stem Fremitus +

Perkusi Sonor Sonor Sonor Sonor
Auskultasi BND Vesikuler, BND Vesikuler, BND Vesikuler, BND Vesikuler,
Rhonki (-) Rhonki (-) Rhonki (-) Rhonki (-)
Wheezing (-) Wheezing (-) Wheezing (-) Wheezing (-)
Jantung
• Inspeksi: iktus kordis tidak terlihat
• Palpasi: iktus kordis teraba di areola mamae sinistra
• Perkusi: tidak dilakukan
• Auskultasi: BJ I dan II murni, murmur (-) gallop (-)
Abdomen
• Inspeksi: tampak datar, pusar tidak menonjol
• Perkusi: hipertimpani (+)
• Palpasi: supel, nyeri tekan (-), hepar tidak teraba membesar, limpa
tidak teraba membesar, turgor kembali cepat.
• Auskultasi: bising usus 3x/menit

Genitalia: fimosis (-), eritema natum (-)

Ekstremitas:
• Superior: edema (-) sianosis (-) akral hangat, CRT<2 detik
• Inferior: edema (-) sianosis (-) akral hangat, CRT < 2 detik
• Pemeriksaan neurologis
• Motorik: koordinasi baik
Penilaian Superior ka/ki Inferior ka/ki
Gerak Normal/normal Normal/normal
Kekuatan Otot 5/5 5/5
Tonus Normotonus/normotonus Normotonus/normotonus
Klonus -/- -/-
Atropi Eutropi/eutropi Eutropi/eutropi

• Kesan: motorik normal

 Pemeriksaan Neurologis
Refleks fisiologis Rangsang meningeal
• R. Biceps (+/+) • Kaku kuduk (-)
• R.Triceps (+/+) • Brudzinsky I (-)
• R. Patella (+/+) • Brudzinsky II (-)
• R. Archilles (+/+) • Kernig sign (-)
Refleks patologis
• R. Babinsky (-/-)
• R.Chaddok (-/-)
• R.Oppenheim (-/-)
Sensorik: sulit dinilai
 Diagnosis Kerja
• Klinis tifoid
 Diagnosis Banding
• ISK
• Demam Typhoid
• Malaria
• Tuberkulosis