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    Morning Report: Department of Internal Medicine

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    Sharifah Filda
    1) A 61-year-old female patient presented with fever for 10 days and nausea/vomiting for 5 days. 2) On examination, she had a fever of 38.3°C, pale conjunctiva, and abdominal tenderness. 3) Laboratory tests showed anemia, leukocytosis, and positive tests for thypoid fever. She was assessed with thypoid fever, anemia, and dyspepsia.

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    Morning Report: Department of Internal Medicine

    Uploaded by

    Sharifah Filda
    12 views13 pages
    1) A 61-year-old female patient presented with fever for 10 days and nausea/vomiting for 5 days. 2) On examination, she had a fever of 38.3°C, pale conjunctiva, and abdominal tenderness. 3) Laboratory tests showed anemia, leukocytosis, and positive tests for thypoid fever. She was assessed with thypoid fever, anemia, and dyspepsia.

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    Morpot Kelompok 1. 22 Juli 2015

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    1) A 61-year-old female patient presented with fever for 10 days and nausea/vomiting for 5 days. 2) On examination, she had a fever of 38.3°C, pale conjunctiva, and abdominal tenderness. 3) Laboratory tests showed anemia, leukocytosis, and positive tests for thypoid fever. She was assessed with thypoid fever, anemia, and dyspepsia.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    12 views13 pages

    Morning Report: Department of Internal Medicine

    Uploaded by

    Sharifah Filda
    1) A 61-year-old female patient presented with fever for 10 days and nausea/vomiting for 5 days. 2) On examination, she had a fever of 38.3°C, pale conjunctiva, and abdominal tenderness. 3) Laboratory tests showed anemia, leukocytosis, and positive tests for thypoid fever. She was assessed with thypoid fever, anemia, and dyspepsia.

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    © All Rights Reserved
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    of 13

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT
    July, 22th 2015
    TEAM 1

    Mrs. M , 61 YO
    CC: Fever
    Findings
    Fever
    GCS: E4M6V5, TD: 100/70, PR 78x, T : 38,3oC, RR: 18x
    Eye : Pale Conjungtiva +/+, Sclera icteric -/THT : Normal
    Neck : Lymph Nodes not Enlarged
    JVP : not distended
    THRORAX

    : intercostal retraction and movement symetric


    Pal: Vocal fremitus symetric, ictus cordis : palpable
    Per: sonor, cardiac enlargment (-)
    Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and
    S2 irreguler, gallop (-), murmur (-)
    ABDOMEN
    Ins : flat
    Aus : Bowel sound (+) 5x/minute
    Pal : Pressure pain in epigastrium(+)
    Per : tympani
    Extremitas : pitting oedem (-), cold acral, CRT < 2, turgor
    normal

    Assesment
    -Thypoid
    fever
    - Dyspepsia
    - Anemia

    Therapy
    MM/
    Levofloxacin 2 x 200 mg
    (iv)
    Paracetamol 3x 500mg
    Sucralfat 3x1c
    Omeprazole 1x40mg
    Hemafort 3x1

    Planning
    Pro Hospitalized
    IVFD : II futrolit/24 hours
    I RL/24 hours
    Chek lab : Ureum,creatinin, SGOT/SGPT

    Subjective Data
    Name
    TC
    CC

    : Mrs. M, 61 years old


    : Wednesday, July, 22th 2015
    : Fever

    Anamnesis
    Main symptom
    Additional symptom

    : Fever
    : Nausea, Vomiting

    Patient came to UKI hospital with Fever since


    10 days before came to hospital. Patients also
    complain of nausea and vomiting since 5 days
    .

    Past Medical History and Treatment


    -

    Family History
    -

    Social History
    Smoking(-), Alcohol (-), excercise (-)

    Objective Data

    Appearance : Moderate Illness


    GCS E4M6V5
    BP : 100/70 mmhg,
    RR: 18x/ minute,
    T : 38,3C
    Pulse : 78x/minute.
    Eye: Pale conjunctiva +/+ , sclera icteric -/Ear, Nose, throat : normal
    JVP : normal

    Thorax.
    I : Intercostal retraction and movement symetric
    Pal: Vocal fremitus symetric, ictus cordis : palpable
    Per: sonor, cardiac enlargment (-)
    Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 irreguler, gallop (-), murmur (-)

    Abdomen.

    I : flat
    Aus : bowel sound (+) 5x/minute
    Per :timpani, percussion tenderness (-)
    Pal : abdominal tenderness (+), liver and spleen enlargement (-)

    Extremity
    -

    Cold
    Capillary refilling time <2 second
    Edema (-)
    Turgor normal

    Clinical Laboratory
    22/07/2015 20:45
    H2TL
    Hb
    Leucosite
    Hematocrite
    Trombosite
    GDS

    :
    :
    :
    :

    9,7 g/dl (Low)


    4.200/uL (High)
    28,4 % (Low)
    153.000/uL

    : 95 mg/dl

    Na : 134 mmol/L
    K : 9,5 mmol/L
    Cl : 102 mmol/L
    S.Thypose H : + 1/320
    S. Thypose o : + 1/ 160

    Assessment
    Thypoid fever, anemia,
    dyspepsia

    Therapy
    Levofloxacin 2 x 200 mg (iv)
    Paracetamol 3x 500mg
    Sucralfat 3x1c
    Omeprazole 1x40mg
    Hemafort 3x1

    Planning

    Pro Hospitalized

    IVFD : II futrolit/24 hours

    I RL/24 hours
    Chek lab : Ureum,creatinin, SGOT/SGPT

    Department of Internal
    Medicine
    Christian University of Indonesia

    Thank You

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