Task 1

Patient N, 25 years old, came from a country of endemic cholera, went to the doctor with a medical unit, complains on
chilling, nausea, single vomiting, abdominal discomfort, watery stool 3-4 times

1) Medical history to find out

 What does the patient eat before the day 1st sign of illness start?
 Check body temperature
 What is his 1st symptom, watery diarrhea or nausea & vomiting
 How is patient’s abdominal pain? Have spasmodic pain or only discomfort?
 Does the patient has intoxication syndrome?
 Does the patient have inflammation syndrome?
 Dehydration symptoms?
 Color of watery stool?
 Does the patient have consciousness of disturbance?

2) Diagnostic search
 Bacteriological method : feces, vomit - add preservative because cholera die in 1-2 hour
 phase of dark field microscopy (use fresh specimen)
 inoculation of specimen from patient or corpse on selective nutritive media :
 alkaline peptone h2o
 TCBS agar – pale-flat, yellow colony, in 12-24 hour, 37°C
 Serological method
 After 5-7th day of disease – on 10th-12th day of disease
 Discover Ab of cholera vibrio
 In blood
 Express diagnostic method
 Detect Ag (1st day disease
 In feces and other materials
 IF method
 Result after 1.5-2 hours

3) Confirmation method : serological method

4) Lab study to conduct

 FBC / CBC – check sodium, potassium, etc
 Hematocrit
 Relative plasma density
 pH level
 Hb level
 CN pressure
 Plasma K+
 Basic electrolyte deficit

5) Therapeutic treatment
 Rehydration therapy (ASAP)
 Compensation of fluid loss & correct metabolism
  Changes and maintain normal hydration
 2 phases : 1 – rehydration (IV) :
 for first 4 hours, 65 < 70kg (2hr - 5l)
 severe : 1st 30 min : 30ml / kg, 80-120ml / 50-100ml/kg/hr
 in severe : USE Lactated Ringer solution NOT NaCl
 saline : for 1st, 2nd stage + not vomiting
2 - maintanence : (oral)
 may up to days in severe case
 800-1000 ml / hr
 Antibacterial therapy
 Antibiotic : LPS  no invasion, no intoxication (fever), no inflammation
 Not curative
 For diminishing duration & volume of fluid loss
 For hasten clearance of organism
 Pramidol + suprastin : for cramps & anaphylactic – cessation of vomiting, give 3-5 day

6) Rule of discharge
 Clinical convalescence
 After the course of antibacterial therapy
 Triple feces inoculation (every 24-36 hour after course of antibacterial therapy
 Bile inoculation (portions B&C – single ; for persons working with food stuff)
 Discharge after rehydration :
 Oral tolerance > 1000ml/hr
 Urine > 40ml/hr
 Stool volume < 400ml/hr

Task 2

Patient S, 34 y.o, carpenter, admitted to infectious hospital for 3rd day of disease

Acute disease : chills, temp 38.2°C, headache, malaise, cramping, abdominal pain, loose stool, “no account” with mucus
blood

The next day, abdominal pain increase, localized to Left, frequent urge to defecation, stool volume decrease, retain fever. On
exam : pale skin, cold hand and feet, body temperature 38.9°C, pulse 110, BP 100/60, rhythmic, satisfactory filling, muffled
heart sound, dry tongue, white coated. On palpation, painful along large intestine predominantly on LLQ. Stool exam, soft
with streak of blood

1) Preliminary diagnosis
 Acute shigellosis colitis variant of moderate form
 Why colitis?
 Acute onset
 Intoxication syndrome (fever)
 Diarhheal syndrome
 Distal spasmodic hemocolitis
 1st defecation : large amount of stool
  Increase no of defecation & change stool consistency
 Decrease volume stool in subsequent defecation in 1st – 2nd day
 Presence mixtures of stool (blood, mucus, pus)
 Abdominal pain in lower abdomen, mostly in L lower quadrant where spasm of sigmoid colon can be
found
 No dehydration

2) Medical history should be taken :

 Any water or food intake by onset of symptom?
 Any family member has the same symptom?
 Any constipation before? (diff dx with chronic, colon cancer)
 What is feature of clinical course?
 Location of abdominal pain, characteristic of pain?
 Condition of stool? – presence or absence of mixture?, frequency? , volume?

3) Pathogenic mechanism of diarrhea

 Exudative inflammation of shigellosis
 Intoxication due to : endotoxin (PGE&PGF) and enterotoxin in endothelial of GIT  triggers the signaling
cascade for macrophage / endothelial cell / cascade biochemical secretion action  resulting in
inflammation  elicit secretion of h2o & electrolyte in GIT : diarrhea, increase motility : nausea & vomiting

4) Leading symptoms
 Pain along large intestine : predominant in LLQ
 Admixtures of stool with blood
 Distal spastic homocolitis (raise urge of defecation)

5) Lab studies
 Gold standard : bacteriological
 Serological
 1st one hour of infection can check Ag in blood, stool, saliva, urine, all bio fluids
 Agglutination test : urine, blood (2nd week)
 Generalized – shigella serotype 1
 Localized – other shigella

6) Medical measures :
 Colitis form : immediately give antibiotic to prevent becoming chronic
 Detoxification : crystalloid
 Antiinflammation : powder / liquid – bismuth subnitrate / NSAID (contraindicationulcer)
 Spasmolytic
 Anti,microbial (etiotropic)
 Enterosorbent  smecta
 Probiotics – after antibiotic therapy ; in moderate & severe

7) Rules of discharge
 3 –ve result in bacteriological test
 1 –ve result in bile inoculation for food worker
Task 3

Pt. 84 y.o , hospitalized. No medical hx taken. On exam : temperature 37.8°C, skin & mucous membrane are dry, pale,
marked acrocyanosis, decrease skin turgidity, pulse 100, arrhythmia, HR 120, cardiac extended to the left, BP 120/90, the
abdomen is involved in breathing & available to palpate. Reacts to palpation on umbilical & epigastric region, painful. Stool is
watery & greenish. Wife said appears loose stool but reject hospitalization

1) Preliminary diagnosis
 Food poisoning, gastroenteritis variant (watery diarrhea, cramp abdomen discomfort in umbilical region, no
colon inflammation) ; resolve after 4 days, if perceive maybe salmonellosis; after 2 week only can check for
salmonellosis

2) Diagnostic research
 Main : bacteriological test for stool ; usually –ve

3) Extra diagnostic
 Serological test
 Observe Ag
 Not typical for food poisoning because ~ 4 days it resolve while this test is informative on 2nd week,
so suitable for salmonellosis
 Coagulation test

4) Severity of patient
 Moderate ; II stage dehydration
 Acrocyanosis
 Decrease turgidity of skin
 Pulse 100 min
 Stool liquid
 Presence cramp abdomen without tonic tension

5) Therapeutic measure
 IV crystalloid (dehydration tx) – clasol, trisol, disol, quartasol
 Spasmolytic drug
 Antibiotic (elder) / young / stomach ulcer
 Drink water

6) Prognosis
 Satisfactory ; not good because old (84 years)

Task 4

Pt, worker, 24 year old, noted 5 days of decrease performance, increase weakness loss of appetite, headache. Went to
doctor & complaints: fever 38.1°C, persistent headache, insomnia. Doctor gave antipyretic, analgesic, vitamins and drink a
lot. No effect. Admitted on 8th day.
On exam, fever 39.2°C, dry skin, pale, apathy, answers correctly but with delay. Dry tongue, thickened with densely coated
brown pontina. Muffled heart sound, 76 pulse, BP 100/60 arrhythmic. Abdomen is breathing rhythmic, tympanic sound of
entire abdomen surface surface exact R iliac region. No stools for 3 days. Revealed that patient has to drink occasionally from
his work, from water supply

1) Preliminary diagnosis
 Acute typical typhoid fever of initial period

2) What is other symptom

 Typhoid tongue – edematous, 1st white  brown (blood), mucous very dry (decr. Salivation)  minimal
erosion in mucous of oral cavity
 Relative bradycardia ( including temp, No include pulse)
 Pale colour skin in background of increase temperature ; dry mucous
 Hyperemia neck
 Meteorism
 Constipation (early diarrhea for few days then due to sys. Interruption  constipate)
 Headache that not cease with analgesic
 Dry cough due to enlargement of lymph node bronchi ( Pirogov lymphatic ring – 1st barrier)
 Appear rash ( roseoulus rash : appear  dissappear  appear)
 Severe headache
 Infectious delirium, disorientation (due to intoxication)


3) Lab studies
 Bacteriological
 1st week : blood culture ( NOT feces, urine because S.typhi not yet reach excrete in organs)
 2nd week : blood / urine / stool culture
 Serological
 5-6th day of disease
 Widal’s test, rxn of indirect hemagglutination with O, H & Vi
 Titer (min) : 1:200, 4x repeated increase of Ab titer (~ =ve)
 Hemogram
 Leucopenia ( due to bone marrow intoxication)
 Neutropenia (shifted to left)
 Uneosinopenia
 Normal ESR
 Lymphomonocytosis

4) Therapeutic measures
 Strict bed regimen : durin fever  7th – 10th day of normal temperature, on 11th day may start walking
 Mix antibacterial therapy : IV ceftriaxone + ciprofloxacin ( during fever + 10 day normalization)
 Diet regimen : no 4 BT(rus) / TF (eng) ,
 Porridge-like
 Dry, white bread
 Fine-minced meat
  Boil food, no alcohol, no fat, no fried, no spicy, no conservative, no seed ( to small  may get into
cavity of ulcer  perforation), no grapes(meteorism), no chiorni xleb, no grape juice, no orange
juice( pt already have hyperkeratinemia, orange juice lead to intoxication)
 Detoxification therapy
 Vitaminotherapy
 Antipyretic remedies
 Symptomatic therapy ; sedative remedies, hypnotic remedies, complex hemostatic therapy(if bleeding),
surgical intervention (if perforation)

5) Complication
 Abdominal ; GI hemorrhage (3-4 week), GI perforation, hepatitis, cholecystitis (usually subclinical), infectious
toxic shock

End of 2nd up to 4th week

 Bleeding
 Decrease of temp in 1-2°C
 Increase pulse
 Pale
 Cyanosis/precyanosis
 Cold sweating
 Severe weakness
 Low BP
 Melena
 Diarrhea black colour feces
 Perforation
 Feel local focus pain (moderate) but not mentioned by patient,
 Rebound pain
 Infectious toxic shock
 Not marked excitement & motor anxety
 Paleness, acrocyanosis, tachycardia, increase dyspnea
 Hypothermia & oliguria process
 Infectious psychosis at height of typhoid fever are described
 Secondary bacterial induce
 Pneumonia
 Arthritis
 Myocarditis

6) Rules of discharge
 Pt w/o antibiotic therapy ; on 13th – 21st day of apyrexia ( no fever), 2nd – 6th week of onset of disease (ulcers
is healed)
 2 –ve bacteriological test of fece & urine
 1 –ve bile insanation control of patient
 1 +ve bacteriological test + no clinical sign  do 2nd course of test maybe disappear (result –ve)  if still +ve
– still can be discharge because he is a carrier. So if he is someone who work with food need to change job

Task 5
On a scheduled check up, pt aged of 22, was admitted for hernia repair with moderate decrease of platelet count, small time
delay of blood clotting of bleeding time. In blood analysis, prothrombin index 66%, Total bilirubin 22 mmol/L, ALT 818 IU/L,
AST 540 IU/L. in general blood analysis, Hb 140 g/L, WBC 3.3, Hbs Ag, anti HCV, anto HIV is negative. On exam, light red
icteric spot can be found, abdomen soft and painless. Liver acts from costal 1.5cm. physiologically normal. On epidemic
anamnesis, injecting drug users, episodes of weakness, dark urine

1) Preliminary diagnosis
 Acute viral hepatitis C : subclinical but no Ab (only in 4-10 week can detect) so assume HCV  check for HCV
RNA

2) Diagnosis research
 Liver function test : done  ALT > AST : prodromal period, very high aminotransferase – severe hep ; check
for alkaline phosphatase (usually mild increase)

3) Serological test
 Ab HCV –ve because only after 4week in 4-10 week only can be detected by  immunofluroscent assay

4) Additional lab test

 Molecular test (PCR), HCV RNA – based on PCR technique
 Biopsy ; for viral hep. C initial detection

5) Treatment
 Detoxification tx : crystalloid
 Symptomatic tx : spasmolytic drug
 Monitor condition in 12 week  if viremia persist after seroconversion give antiviral tx  ribovirin + INT

6) Prognosis
 Good

Task 6

Pt. aged 18 y.o, injected drug, hospitalized strong demand by parent who noted the appearance of jaundice of the skin &
sclera. Complained : objectively visible yellowish colour on skin & mucous membrane, abdomen soft, painless, liver act from
costal to 2cm, dark urine, feces coloured. Prothrombin index 63%. Direct bilirubin 39 mmol, indirect bilirubin 30 mmol. In
general the analysis of blood : Hb 168 g/L, leukocytes 7.6, ELISA detected anti-HCV IgG in serum. In PCR detected RNA NSO (
) 1:10,000

1) Preliminary disease
 Chronic hepatitis C (immune response inadequate + no clinical sign)

2) Diagnostic research
 Liver function test
 Serological test : immunofluroscent assay – dtetct Ab (in 4w -10w)

3) Evaluation result
 Prothrombin index (N 10-12) : inc
 Direct bilirubin (N0.8-6) : inc
 Indirect bilirubin (N ) : inc
  Hb ( N 130-170) : N
 Leukocytes (N 4-11) : N

4) Additional lab
 PCR : find HCV RNA
 Biopsy

5) Treatment
 Combo antiviral therapy : ribavirin + INT – for 11 month
 Symptomatic tx : jaundice : spasmolytic drug : protaverin
 Detoxification

6) Prognosis
 chronic infection stay for lifetime : may develop cirrhosis

Task 7

Pt M, 28 y.o, contact your doctor clinic, complaining of hardness in RUQ, nausea, loss of appetite, weakness, which appeared
2 weeks ago.
Explain in his illness, exacerbation of chronic gastroduodenitis ; therefore begin to receive motilum; lanitidine.
On exam : body temperature 36.5°C, normal skin color, R marginal subicteric sclera. Pulse 64, BP 106/60. Tongue lined, white
coated, soft abdomen, painful on palpation in epigastric of RLQ. Liver 1.5cm stands out of costal margin. Soft consistency.
Physiological function are normal.

CBC : Hb 128 g/L, WBC 4.8, ESR , urine colour : yellow, acidic with pigment, total bilirubun : 38.0, ALT 104.5, AST 105.4, AP
584. Thymal lost 34. Hepatitis marker HAV +ve

1) biochemical & serological indicate to research

 serological test
 Ig M HAV
 Ig M Ab / Anti HAV
 Ig G anti HAV
 Biochemical
 Liver function test
 Stool culture

2) Lab test show parenchymal pt.

 Inc AP – 854 – cholestasis sign
 Inc ALT > inc AST – liver damage
 Thymol : 34 ; inc – marker acute hepatitis
 Total bilirubin inc : liver function dysfunction

3) Medical history
 Color of urine? Any abnormal? If yes, when?
 Have visited / come fro Africa, Central, SEA, Latin America
 How hygiene of home, working place
 Recently have been admitted in hospital?
  Sex life?
 Stool colour?
 Have itching?

4) Formulated diagnosis
 Acute hepatitis A

5) Treatment technique
 Prevention
 Vaccination
 Passive immunization

6) Prognosis
 Good, immunity lifetime

Task 8

Pt. 15 y.o, supporter of hare Krishna, appeared with moderate pain in throat when swallowing, low grade fever. After 2 days,
on a background therapy (erythromycin garging antibiotic) joined with liquid watery stool with abdominal pain, large joints
pain & spots on skin. Fever reactivated febrile digit. Doctor charges to antihistamines therapy, but following days fever
remain high, disturbed moderate stomach pain, laxative stool 3-4x a day. There are swelling redness, stiffness & sharp pain
when palpated. On 10th day of disease, body temperature 39.7°C, hyperemia. Bright erythema & edema of skin, knee, elbow,
ankles & toes. Pulse 120, BP 100/80. Cardiac normal thickenend, white & coating tongue. Hyperemia & granula form on
posterior pharyngeal wall.
abdominal pain with palpation & rumbling. Predominantly in R iliac region. Stool like paste 1 times/day. Palpable livers &
spleen. Painful urination CBC. Hb 100 g/L, WBC 18.8. ESR 40mm, urine colour yellow, acidic, specific gravity 1018. Blood
analysis 38 mmol. ALT 140, AST 80, prothrombin index 88%, Ab titer salmonella & brucellosis 1:100

1) Identify leading symptom

 Abdominal pain localized at R iliac region
 Pharyngitis, catarrhal tonsillitis
 Diarrhea only; 10 days duration (>12 day usually salmonellosis)
 Hepatolienal symptom
 Rash symptom (erythema)
 Arthropathy
 Intoxication : fever
 Pyelonephritis / pain in urination + arthritis 

2) Preliminary diagnosis
 Acute yersiniosis secondary local form , moderate

3) Diagnosis research
 Microbiological culture : culture – stool, blood, throat swab; after 4w still +ve  acute
 PCR & immunofluroscent assay
 Serological test : widely
 Agglutination assay, ELISA & immunoblotting : detect Ig G, Ig M, Ig A
  +ve Ig M – support dx, 4 fold rise between acute & convalescent, after 2w onset if Ab titer not
observed, repeat after several day because Ab titer appear later in yersiniosis, increase titer 
exacerbation, decrease titer  remission
4) Treatment tactics
 Antibacterial therapy : pt have intoxication & arthritis
 Duration : in 2w till 10day of normalization = 3w, make sure not less than 2 month
 Antibiotic tx is short duration effectiveness, so if after 7 days there is no improvement means
antibiotic not effective
 Anti-inflammatory therapy
 Anti-allergic
 Probiotics ( yersinia lead to dysbiosis, so give after antibiotic < 10 months, eg : lactobactinine)

5) Tactic of survey at point of reference

6) Prognosis
 Not good

Task 9

Pt, 33 y.o, hospitalized in department of hepatitis with complained of jaundice, weakness, nausea, lack of appetite. On exam,
bright skin of mucus membrane. Palpation of R hypochondrium is painful. Size of Kurlov liver is 10x9x8. Clear consciousness,
focused euphoric.
Hb – 0.8g/L, leukocytes 3.8 g/L, ESR 8, total bilirubin : 220 mmol, direct bilirubin 100.0, ALT 2046, AST 2540, AP 384,
Prothrombin index 662, marker of hepatitis : Hbc Ag Ig M +ve.
Not sleep at night, repeated vomiting, bloating and pain R region. In morning wakes up & sleep at another bed

1) Preliminary diagnosis
 Hepatitis B (co-infection with hepatitis D), icteric form

2) Severity?
 Severe

3) Interpretation of serological test

 Serological test
 Hepatitis marker , inc ALT, inc AST, +ve Hbs Ag, +ve anti Hbc Ig G, +ve anti Hbc Ig M

but HDV Ag, HDV RNA is not detected  not chronic infection
anti HDV Ig G & anti HDV Ig M  not detected

# co-infection of hepatitis D

4) What research?
 PCR  HDV RNA
 Re-do serological test to detect : anti HDV ig M and anti HDV Ig G
 Do serological profile
 5) Management patient
 Detoxification therapy
 Crystalloid : colloid  3:1
 Abundant of H2O
 Drug for hypokalemia correction
 Enterogel, enterosorbent
 Enzymes (short-time , 7-10days)
 Agent decrease absorptive function
 Lactulose
 Duphalac
 Diet no 5
 No spice, no meal fat, no fizzy drink, no chemical
 Against background of limited protein intake (diet 5)
 Amino acid solutions  for hepatic failure
 Aminosteril N-hepa
 Hepatosteril A
 Hepatosteril B
 Hepatamine
 Aminoplasmal heap-10%
 Spasmolytic drug
 Drataverine
 Euphylin
 Drug used to treat cholestasis
 Uredeoxycholic acid  ursofalk, ursosan
 Diuretic
 Spironolactone
 Antibiotics (low resorbtion from intestine)
 Aminoglycosides
 Antiviral + immunosuppressant
 For hepatic encephalopathy  chilled plasma
 For hemolytic syndrome  amino acid solution
 For ammonia  osmotic diarrheal drugs

6) Prognosis

Task 10

Pt, work in slaughter house, acute ill with severe vomiting. Increase temperature 38.9, headache, muscle & joint pain. Taken
to hospital at 4th day of illness. Pt on admission, body temp 39.8C, puffy face, blood shot, cold sores on lips. Sclera inject
icteric with hemorrhages. Rash with hemorhhagic component on skin of trunk & limbs. Hand have traces of multiple cuts
during cutting pig. Passive position because pain at front of abdominal wall, lower back & legs. Palpation of calf is extremely
painful. Muffled heart sound. Pulse 120, BP 90/60. On palpation : ant. Abdominal wall is painful, liver at 3cm costal margin.
50ml dark muddy urine.
CB : hb 128, WBC 158, ESR 45. Biochem blood analysis : total bilirubin 50, direct bilirubin 35, ALT 210, AST 110, AP 285, PI
80%, creatinine 143, urea 17

1) Highlight the main symptom

  Acute ill, chills
 FUO fever at unknown origin (high fever, 3-7 days)
 Arthralgia
 Myalgia
 Hepatomegaly

2) Severity condition
 Severe  intoxication syndrome, hemorhhagic syndrome, jaundice

3) Evaluation result
 Hb : N (130-175)
 WBC
 ESR
 TB
 DB
 ALT
 AST
 AP
 PI
 Creatinine
 Urea

4) Preliminary diagnosis
 Acute brucellosis

5) Additional diagnosis
 Blood / bone marrow / tissue culture : at early disease, incubate culture for 6w
 Serological test
 Should be taken very early
 To detect botulinum sp in 2 week
 SAT
 Using B.abortus strain 119
 Measure : Ig M, Ig G
 Not detect : Ab to B.canis
 Detect : B.abortus, B.suis, B. mertensi
 Indications  1:160 titer  active infection
 ELISA
 Detect Ig G, Ig M, Ig A
 Immunoblotting analysis of cytoplasmic Ag
 PCR
 Histologic findings  analysis liver biopsy specimen & bone marrow specimen
 CSF
 Inc protein level
 Decrease sugar level
 +ve culture
 Ab present in most
 6) Treatment
 Optimal combine long-term antibiotic therapy (not < 6w, better 2 month)
 Rifampicin
 Doxycycline
 Gentamicin if pt have endocarditis

Task 11

Driver of long distance trucks. Acutely ill with severe chill, increase temperature 39.3, headache, muscle & joint pain. Relative
of pt caused SMP on 4th day because pt has massive nose bleeding, increase temperature, disturbed consciousness. On
admission, body temperature 40C, confused mind, puffy face, bloodshot, hemorrhagic icteritis, light icterus sclera & mucous
membrane, hemorrhagic crisis in nasal passage. On the skin of trunk & linb, petechiae element rash with concentration in
natural fold & places pressure garments.
Muffled heart sound, pulse 120, BP 100/60, from under costal, palpable liver edge and lower pole of spleesn. Dark colored
urine. Determine rigidity of neck. Kernig sign.
CBC : hb 100, WBC 18, ESR 40
Biochemical analysis : TB 45.9, ALT 130, AST 115, PI 82%, creatinine 105, urea 13mmol
anamnesis : suburban trip, powdered henna wheels. Use H2O for drinking & hygiene purpose of natural H2O

1) Main symptoms
 Hepatolienal symptoms
 Meningitis (kernig’s sign) , increase sign, stiff neck, disturbed conciousnees,
 Hepatitis B (icteric : have haemorhagic syndromes
 Athropathy (arthralgia)

2) Severity of patient’s condition

 Moderate

3) Evaluation result
 ALT & AST
 TB
 PI
 Hb
Hepatitis B

4) Preliminary diagnosis
 Gen yersiniosis moderate form

5) Additional test
 Microbiological culture : culture of blood , joint fluid, abcess material
 Specific Ag in stool, blood
 Serological test in serum : 1-2 w after onset (4fold yersinia)
 Routine blood test

6) Treatment
  Strict bed regimen
 Combine tx antibiotic
 Anti-inflammation therapy : NSAID
 Diet 3  boil, minced, porridge-like, no alcohol, no fried, no fat etc

Task 12

Soldier taken to hospital with diagnose of “scarlet fever” on 1st day of illness. Objective : body temperature 38.2C, face
hyperemic, somewhat puffy. Vascular injection of sclera, oropharyngeal mucosa hyperemia. In hand, back of throat, tonsils,
enlarge to 1 degree. Lymph node are small. On sum at hyperemic background punctuate macropapular rash. Griaze
symptom +ve while dermographism. In the area of knee 2 elbow joints, hands & feet is determined menocelin inclined to
merge, joints are painful in movement. Muffled heart sound, clean rhythmic no pulse, BP 100/70. Abdomen soft, tenderness
in R iliac region. One time watery stool

CBC : hb 34, WBC 12.0, ESR 35.

Biochemical analysis : TB 30, ALT 135, AST 105
Anamnesis : diagnose of scarlet fever. The pt is placed 3rd time on 2 previoud episodes of diagnoses was treated with
penicillin & erythromycin in a military unit. Last month diagnose case of scarlet fever

1) Main symptom
 Scarlet fever-like
 Catarrhal tonsillitis  oropharyngeal mucosa hyperemia, back of throat, tonsil enlarge by increase
degree
 Red rash  macropapular rash
 Abdominal pain similar to appendicitis R iliac region
 Intoxication syndrome : fever
 Arthralgia
 One time watery diarrhea

2) Severity condition
 Moderate

3) Evaluation test
 Hb
 WBC
 ESR
 TB
 ALT
 AST

4) Preliminary diagnosis
 Scarlet fever-like, generalized yersinosis, moderate form

5) Additional lab
 Specific Ag : stool, blood
 Serological test : immunoassay
6) Treatment
 Strict bed regimen
 Mixed antibiotics therapy : ceftriaxone + ciprofloxacin
 Diet 3
 Anti-inflammatory therapy (NSAID)
 Antiallergic