Tifoid Rafid

CASE REPORT
Thypoid Fever
Mentor :
dr. Nurifah, Sp. A
Presented by :
Rafid - 1102016175
FACULTY OF MEDICINE, YARSI UNIVERSITY
BHAYANGKARA TK. I R. SAID SUKANTO HOSPITAL
20TH SEPTEMBER – 30TH OCTOBER 2021 PERIOD
CONTENTS OF THIS CASE REPORT
Case Illustration Literature Review Case Analysis
To understanding what is Thypoid Fever

Patient’s Identity
• Name : Child NFS CHIEF COMPLAINT
• Date of birth : Jakarta,
20
/09
Fever since 15 days
before admision
1.
November 11th 2004
• Gender : Female
• Age : 16 years 11 months
ADDITIONAL COMPLAINTS
Religion : Muslim
•
• Address : Komplek zenu ada
2.
rawa jati Nausea and vomiting 3x a day since 5
days before admision
• Last Education : Junior high
school
• Date of entry : September 20th
2021, 01.15 WIB
• Check date : September 20th
2021, 10.00 WIB
Additional Complaint
Complaints of cough without phlegm,

dizziness and defecation were felt by the
patient since 2 days of admision then the
patient was taken to a general practitioner
clinic and given paracetamol, omeprazole
and antibiotics but the complaints were still
felt and did not improve
ADDITIONAL INFORMATION
FAMILY HISTORY OF
PAST MEDICAL HISTORY
ILLNESS
-Typhoid fever in 2016
- DHF 2017 The family did not experience similar
complaints and there was no history of
- Appendicitis in 2018 hypertension, diabetes mellitus, TB,
asthma or drug allergies
- Dyspepsia
ALLERGY HISTORY MEDICINE HISTORY
The patient has no allergy
Sanmol 3x1 Tab in 6 days but
reaction to certain
the fever not getting any better
food/drugs/things.
ADDITIONAL INFORMATION
History Of Pregnancy And Immunization History

Childbirth
The patient's parents said
At
The
The birth, thewas
patient
patient's
patient cried
mother
born loudly,
did
section
The remaining body weight that the patient was
the membranes
caesarea
not assisted
have bywere clear,
a doctor
complications atand
was 3000 grams
was immediately
hospital with 9 months and ofthe
given an completely immunized.
during pregnancy.
birth length
injection was 48Kcm.
of (G2P1A0).
gestation vitamin and
hepatitis B vaccine.
Growth and Development Feeding History
History
The patient for 1.5 years was given
The mother says that the exclusive breastfeeding. After the age of 8
The patient is given full 6
child grows and months, the patient was given
months of breastfeeding
develops just like any complementary foods such as porridge,
fruits, baby biscuits and formula milk.
other child.
Personal, Social, and Economic History
The patient lives in a boarding school and has the
habit of snacking food randomly around the
boarding school environment. Before the
complaint appeared, 6 of his friends at
theboarding school also complained about the
same complaint as the patient
PHYSICAL EXAMINATION
General condition : Looks moderately ill Anthropometric data
(CDC percentile
curve)
Conciousness : Compos mentis
• Weight : 70 kg
(GCS: E4M6V5)
• Height : 165 cm
Vital Signs:
• Age : 16 year 11 month
a. Heart rate : 88x /minutes • Weight for age x 100% = 129 %
(overweight)
(regular, strength lift)
• Height for age = x 100% = 101 %
b. Respiration rate : 22x /minute (normal)
c. Temperature : 36.6° C • Weight for height = x 100% = 129%

(overweight)
d. Blood pressure : 110/80 mmHg
e. SpO2 : 99%
Head : Normocephal,
Eye : Conjunctiva is not pale, sclera is not icteric, cornea is clear, pupil is round
symmetrical (3mm / 3mm)
Ear : deformity - / -, no secretions
Nose : deformity - / -, no septal deviation, no visible secret, no nasal lobe breath
Throat : Walls are not hyperemic, T1 / T1, lesions (-)
Neck : no palpable enlargement limph node, trachea in the middle, neck

stiffness absent
Lungs
Inspection : Normal form, symmetrical in a static and dynamic state, retraction (-)
Palpation : vocal fremitus the right side same as the left side
Percussion : Sonor in both side, pulmo-hepatic border normal
Auscultation : Vesicular breathing sound (+/+), rhonchi (-/-), wheezing (- / -)
Heart
Inspection : Ictus cordis is not visible
Palpation : Ictus cordis palpable in left midclavivle line ICS IV
Percussion : Cardiomegaly (-)
Auscultation : Normal SI / II, no adding sound, murmur (-), gallop (-)
Physical Examination
Abdomen
Inspection : looks flat, no lession
Auscultation : Bowel sounds (+) 6 times / minute (adequate)
Percussion : Tympanic the entire quandran of the abdomen
Palpation : Supple, liver and spleen not palpable, fast turgor, tenderness at
epigastric and right hipocondrium (+)
Extremities
Superior : warm acral (+/+), Edema (-/-), CRT <2 seconds, lesions (-)
Inferior : warm acral (+/+), Edema (-/-), CRT <2 seconds, lesions (-)
ADDITIONAL EXAMINATION
Hematology (20/9/21)
Result Normal Range Unit

Haemoglobin 14,1 14 - 18 g/dL
Hematocrit 41 40 – 54 %
Leukocytes 12610 5,0 – 10,0 10³ / μL
Erythrocytes 5,19 4,2 – 5,4 10⁶ / μL
Platelets 276.000 150.000 – 450.000 10³ / μL
Segment 65 35 – 70 %
Lymphocytes 28 20 – 40 %
Serology Widal Test (20/09/21)
Result Normal Range

Salmonella Typhi O Negative Negative
Salmonella Para Typhi AO Negative Negative
Salmonella Para Typhi BO Negative Negative
Salmonella Para Typhi CO + 1/320 Negative
Salmonella Typhi H Negative Negative
Salmonella Para Typhi AH Negative Negative
Salmonella Para Typhi BH Negative Negative
Salmonella Para Typhi CH Negative Negative
Urinalysis (20/9/21)
Result Normal Range Unit Result Normal Range Unit
Colour Yellowish - - Leukocyte Negative Negative

Purity cloudy - - Leukocyte cells 0–1 0–5 / SFV
pH 6.5 5 – 8.5 - Erythrocyte 0–1 1–3 / SFV
Density 1.022 1.000 – 1.030 - Epithelium cell 1+ - -
Protein Negative Negative - Cylnder - - -
Bilirubin Negative Negative - Crystal - - -
Glucose Negative Negative - +1
Others : - -
Ketone Negative Negative - bactery
Blood/ Hb Negative Negative -
Nitrite Negative Negative -
Urobilinogen 0,1 0,1 – 1,0 IU
“ Working Diagnosis
A child named NFS, 16 years 11 months with

Thypoid fever
MANAGEMENT
Co-Asisstant’s
Pediatrics Doctors’s Treatment Treatment
1. IVFD RL 20 tpm Medikamentosa

IVFD RL 32 tpm
2. Ceftriaxon 1 x 2 gr IV Ceftriaxon 1 x 2 gr IV
3. Ranitidine 2 x 50 mg IV Ranitidine 2 x 50 mg IV
Ondansentron 3x 4mg IV
4. Domperidone 3x1 Tab Paracetamol 3 x 500 mg
5. Nac 3x1 Tab
PROGNOSIS
Quo ad vitam : dubia ad

bonam
Quo ad functionam : dubia ad

bonam
Quo ad sanationam : dubia ad

bonam
FOLLOW UP (21/09/2021)
S O
General Condition : Looks weak; Consciousness: CM
Vital Signs:
A
• Thypoid fever
• Acute upper
Fever (-) respiratory
• Nausea and vomiting BP: 110/80 mmHg Pulse: 80x/min infection
(+) RR: 20x/min temp: 36.6°C SpO²: 98%
• Cough (+)
Physical examination:
P
• Liquid defecation and
urinate smoothly Eyes: AC (-/-), IS (-/-), sunken eyes (-/-)
Nose & ear: deviation (-), lession (-), secret (-)
Mouth & throat: wet oral mucosa, dry lips, lession (-)
Lungs: VSB(+/+), rhonchi (-/-), wheezing (-/-), retraction (-) • IVFD RL 32 tpm
Heart: normal BJ S1 / S2, murmur (-), gallop (-) • Ceftriaxon 1 x 2 gr IV
Abdomen: Flat, supple, stretcher noise (-) normal,
(day 2)
organomegaly (-), tenderness (+) • Rantin 2 x 50 mg IV
Extremities: warm acral, edema (-/-//-/-), good turgor, CRT • Ondansentron 3x
<2 sec
4mg IV
• Paracetamol 3 x 500
mg
FOLLOW UP (22/09/2021)
S O
Vital Signs:
A
• Thypoid fever
• Acute upper
3 times (+) RR: 22x/min temp: 36.6°C SpO²: 98%
• Cough (+)
P
• defecation (-) and
Lungs: VSB(+/+), rhonchi (-/-), wheezing (-/-), retraction (-)
Heart: normal BJ S1 / S2, murmur (-), gallop (-) • IVFD RL 20 tpm
Abdomen: Flat, supple, stretcher noise (-) normal, • Ceftriaxon 1 x 2 gr IV
organomegaly (-), tenderness (+) (day 3)
Extremities: warm acral, edema (-/-//-/-), good turgor, CRT • Rantin 2 x 50 mg IV
<2 sec • Domperidone 3x1
Tab
• Nac 3x1 Tab
FOLLOW UP (23/09/2021)
S O
Vital Signs:
A
• Thypoid fever
• Acute upper
(+) RR: 20x/min temp: 36.9°C SpO²: 98%
P
• Cough (+)
• Liquid defecation and Physical examination:
(day 4)
Extremities: warm acral, edema (-/-//-/-), good turgor, CRT • Domperidone 3x1
<2 sec
Tab
• Nac 3x1 Tab
FOLLOW UP (24/09/2021)
S O
Vital Signs:
A
• Thypoid fever
• Acute upper
(+) RR: 23x/min temp: 36.5°C SpO²: 98%
• Cough (+)
P
• defecation (-) and
(day 5)
Extremities: warm acral, edema (-/-//-/-), good turgor, CRT • Domperidone 3x1
<2 sec
Tab
• Nac 3x1 Tab
Literature
02 Review
INTRODUCTION
Typhoid fever is an acute systemic infectious disease

caused by Salmonella typhi. The disease is characterized
Definition by prolonged fever, sustained by bacteremia without
involvement of endothelial or endocardial structures and
bacterial invasion and multiplication into mononuclear
phagocytic cells from the liver, spleen, intestinal lymph
nodes and Peyer's patches.
EPIDEMIOLOGY
The age of affected patients in Indonesia (endemic areas) is reported to be between 3-19 years,
reaching 91% of cases because at that age people tend to have a lot of physical activity, so they
pay less attention to their diet, as a result they tend to prefer to eat outside the home, most of
whom pay little attention to hygiene. The incidence of typhoid fever is especially common in school-
age children. The frequency of snacking indiscriminately, with the level of cleanliness still lacking, is
a factor in the transmission of typhoid fever. Salmonella typhi bacteria multiply in food that is less
hygienic
ETIOLOGY
Typhoid fever is caused by the bacteria Salmonella

typhi or Salmonella paratyphi of the genus Another factor that affects the incidence of typhoid
fever is nutritional status. Poor nutritional status
Salmonella. This bacterium is rod-shaped, gram-
can reduce the child's immune system, so that
negative, does not form spores, is motile, children are susceptible to disease, even poor
encapsulated and has flagella (moves with vibrating nutritional status can cause the mortality rate of
typhoid fever to be higher. Decreased nutritional
hairs).
status in patients with typhoid fever due to lack of
appetite (anorexia), decreased absorption of
nutrients due to injuries to the digestive tract and
the patient's habit of reducing food when sick.
Increased lack of fluids or nutrients in patients with
typhoid fever due to diarrhea, nausea or vomiting
and continuous bleeding caused by a lack of
platelets in the blood so that wound clotting
decreases.
PATOGENESIS
Clinical Manifestation
• Step Ladder type fever

• Constipation or diarrhea
• Abdominal discomfort
• Relative bradycardia
• Coated tongue
• Consciousness Disorder
• Rose spot
DIAGNOSIS
HISTORY TAKING PHYSICAL ADDITIONAL

● The fever rises gradually every EXAMINATION EXAMINATION
day, reaching its highest ● Clinical symptoms vary from mild to
temperature at the end of the first ● The definitive diagnosis of typhoid fever
severe with complications. Decreased
week, the second week the fever depends on the isolation of S thypi blood,
consciousness, delirium, most children
continues to be high bone marrow or certain anatomic lesions.
have a typhoid tongue that is dirty in the
● Children often delirious The presence of clinical symptoms of
middle and the edges are hyperemic,
(delirium), malaise, lethargy, typhoid fever or detection of a specific
meteorismus, hepatomegaly are more
anorexia, headache, abdominal antibody response is suggestive of
common than splenomegaly. Sometimes
pain, diarrhea or constipation, typhoid fever but not definitive. Blood
crackles are heard on lung examination
vomiting, flatulence culture is the gold standard for diagnosis
● In severe typhoid fever can be of this disease
found decreased consciousness,
seizures, and icterus
DIAGNOSIS
Peripheral blood:
a) Anemia, generally occurs due to bone marrow suppression, iron deficiency, or
intestinal bleeding
b) Leukopenia, but rarely less than 3000/ul
c) Relative lymphocytosis
d) Thrombocytopenia, especially in severe typhoid fever
e) LED (Blood Endurance Rate): Increases
Serology :
1. Widal
2. TUBEX
3. enzyme immunoassay (EIA) DOT
4. enzyme-linked immunosorbent assay (ELISA)
5. Dipstick
Gall Culture
Radiologic examination (thorac and abdomen)
Differential diagnose COMPLICATION
a) Infections due to viruses (dengue, influenza) • Intestinal complication
Intestinal bleeding
b) Malaria bowel perforation
c) Bronchopneumonia • Extraintestinal
haematological
typhoid hepatitis
typhoid pancreatitis
myocarditis
toxic typhoid
TREATMENT
1. Rest and Treatment
Bed rest and professional treatment aim to prevent complications. Bed rest with full
care in bed, such as eating, drinking, bathing, urinating and defecating will help and
speed up the healing period. In maintenance, it is very important to keep the bed,
clothes, and equipment clean. Typhoid fever patients need to be hospitalized for
isolation, observation and treatment. Patients should be on absolute bed rest for at
least 7 days free of fever or approximately 14 days. The purpose of bed rest is to
prevent complications of intestinal bleeding or intestinal perforation. Mobilization of
the patient should be done gradually, according to the recovery of the patient's
strength. Patients with decreased consciousness, body position should be changed
at certain times to avoid complications of hypostatic pneumonia and decubitus.
Defecation and urination must be considered because sometimes constipation and
urinary retention occur.
TREATMENT
2. Nutrition Management
Patients with typhoid fever during treatment must follow the diet instructions recommended by
the doctor for consumption, including:
a. Foods with enough fluids, calories, vitamins & protein
b. Does not contain much fiber.
c. Not stimulating and does not cause a lot of gas.
d. Soft foods are given during breaks
3. Antibiotics
• Chloramphenicol (drug of choice) 50-100 mg/kg/day, orally or IV, in 4 divided doses for 10-
14 days.
• Co-trimoxazole 6 mg/kg/day, orally, for 10 days
• Ceftriaxone 80 mg/kg/day, intravenously or intramuscularly, once daily, for 5 days.
• Amoxicillin 100 mg/kg/day, orally or intravenously, for 10 days
4. Surgery
Surgery is required in complicated bowel perforation
Prevention
Prevention of Salmonella typhi infection can be done by implementing
a clean and healthy lifestyle. Various simple but effective things can be
started early by everyone to maintain personal and environmental
hygiene, such as getting used to washing hands with soap before
eating or touching eating/drinking utensils, consuming nutritious food
and drinks that have been cooked thoroughly, to minimize the
possibility of contamination. .thypi, then each individual must pay
attention to the quality of the food and drinks they consume.
Typhoid fever vaccine Currently, there are three types of vaccines for
typhoid fever, namely those containing killed germs, live germs and the
Vi component of Salmonella typhi. Vaccines containing killed
Salmonella typhi, S paratyphi A, S paratyphi B (TAB vaccine) have
been used for decades by subcutaneous administration; however, this
vaccine provides only limited immunity, despite frequent local side
effects at the injection site.
PROGNOSIS
The prognosis of typhoid fever patients depends on the appropriateness of

therapy, age, previous health conditions, and the presence or absence of
complications. In developing countries, the mortality rate is >10%, usually
due to delays in diagnosis, treatment, and treatment. Complications, such
as gastrointestinal perforation or severe bleeding, meningitis, endocarditis,
and pneumonia, result in high morbidity and mortality
CASE
03 ANALYSIS
CASE ANALYSIS
DEFINITION
Literature Case
• Typhoid fever is an acute systemic infectious • The patient complains of a fever
disease caused by Salmonella typhi. Fever that continues to rise since 14
that rises gradually every day, reaching the days of SMRS, especially at night
highest temperature at the end of the first
week, the second week of continuous high
fever (Step ladder), especially afternoon to
night
Risk Factor
Literature Case
The frequency of snacking indiscriminately,
with the level of hygiene still lacking, is a factor The patient has a history of eating non higieny snacks
in the transmission of typhoid fever. in the boarding school environment.
Salmonella typhi bacteria multiply in food that
is not hygienically maintained
CASE ANALYSIS
Literature Clinical Manifestation Case
• Intermittent fever 10-14 days The patient complained of fever for 14 days that rose
• Digestive tract disorders continuously, especially at night, then the patient
• Impaired consciousness complained of symptoms of nausea and vomiting and
• Rose spot on chest constipation.
CASE ANALYSIS
Literature DIAGNOSIS: Case
Additional Examination
In this patient, the following examinations

• Peripheral blood were performed:
• Widal Test • Widal test
• TUBEX test • Complete Hematology
• Enzyme immunoassay (EIA) DOT . method • Urinalysis
• Enzyme-linked immunosorbent assay (ELISA) • Thorax X-ray
method
• Planned abdominal ultrasound
• Dipstick examination
• Culture (Gall culture) examination
• Thorax and abdominal X-ray
CASE ANALYSIS
Literature MANAGEMENT Case
bed rest • IVFD RL 20 tpm
Foods with enough fluids, calories, vitamins & protein
Does not contain much fiber. • Ceftriaxone 1 x 2 gr IV
Not stimulating and does not cause a lot of gas. • Ranitidine 2 x 50 mg IV
Soft foods are given during breaks.
Antibiotics
• Domperidone 3x1Tab
Chloramphenicol (drug of choice) 50-100 mg/kg/day, orally or IV, in 4 • Nac 3x1 Tab
divided doses for 10-14 days.
Co-trimoxazole 6 mg/kg/day, orally, for 10 days
Ceftriaxone 80 mg/kg/day, intravenously or intramuscularly, once daily,
for 5 days.
Amoxicillin 100 mg/kg/day, orally or intravenously, for 10 days
Surgery
Surgery is required in complicated bowel perforation
RESOURCES
1. Alan R. Tumbelaka. Diagnosis dan Tata laksana Demam Tifoid. Dalam Pediatrics Update. Cetakan pertama; Ikatan Dokter Anak Indonesia.
Jakarta : 2003. h. 2-20.
2. Ikatan Dokter Anak Indonesia (2008). Buku Ajar Infeksi & Pediatri Tropis. Jakarta: Badan Penerbit IDAI
3. Ikatan Dokter Anak Indonesia (2009). Pedoman Pelayanan Medis IDAI

4. Munaf, S., 2009, Kumpulan Kuliah Farmakologi, Edisi II, Buku Kedokteran EGC, Jakarta
5. Nelwan, RHH. 2012. “Tata Laksana Terkini Demam Tifoid”. CDK-192/ vol. 39 no. 4, th. 2012. Divisi Penyakit Tropik dan Infeksi
Departemen Ilmu Penyakit Dalam, FKUI/RSCM-Jakarta
6. Soedarmo, Sumarmo S., dkk. Demam tifoid. Dalam : Buku ajar infeksi & pediatri tropis. Ed. 2. Jakarta : Badan Penerbit IDAI ; 2008. h. 338-
45.
7. Pawitro UE, Noorvitry M, Darmowandowo W. Demam Tifoid. Dalam : Soegijanto S, Ed. Ilmu Penyakit Anak : Diagnosa dan
Penatalaksanaan, edisi 1. Jakarta : Salemba Medika, 2002:1-43.
8. Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S. Buku Ajar Ilmu Penyakit Dalam Jilid III edisi V. Jakarta: Interna Publishing;
2009.
9. Widoyono. 2005. Penyakit Tropis. Jakarta : Erlangga
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CASE REPORT

Case Illustration Literature Review Case Analysis

To understanding what is Thypoid Fever

Complaints of cough without phlegm,

History Of Pregnancy And Immunization History

c. Temperature : 36.6° C • Weight for height = x 100% = 129%

Ear : deformity - / -, no secretions

Nose : deformity - / -, no septal deviation, no visible secret, no nasal lobe breath

Throat : Walls are not hyperemic, T1 / T1, lesions (-)

Neck : no palpable enlargement limph node, trachea in the middle, neck

Result Normal Range Unit

Result Normal Range

Result Normal Range Unit Result Normal Range Unit

Colour Yellowish - - Leukocyte Negative Negative

A child named NFS, 16 years 11 months with

1. IVFD RL 20 tpm Medikamentosa

Quo ad vitam : dubia ad

Quo ad functionam : dubia ad

Quo ad sanationam : dubia ad

Typhoid fever is an acute systemic infectious disease

Typhoid fever is caused by the bacteria Salmonella

• Step Ladder type fever

HISTORY TAKING PHYSICAL ADDITIONAL

The prognosis of typhoid fever patients depends on the appropriateness of

In this patient, the following examinations

3. Ikatan Dokter Anak Indonesia (2009). Pedoman Pelayanan Medis IDAI

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