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    Morport 8 Juni 2014

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    Agustina Anggraeni Purnomo
    Mr. MR, a 24-year-old male, presented with vomiting for one week. He reported nausea after eating and fever two days prior. Previous medications provided no relief. Examination found moderate illness, rhonchi sounds in lungs, and edema. Laboratory tests indicated typhoid with positive Widal test for Salmonella typhi and paratyphi. The patient was diagnosed with typhoid fever and hospitalized for IV antibiotics and supportive care.

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    Morport 8 Juni 2014

    Uploaded by

    Agustina Anggraeni Purnomo
    36 views5 pages
    Mr. MR, a 24-year-old male, presented with vomiting for one week. He reported nausea after eating and fever two days prior. Previous medications provided no relief. Examination found moderate illness, rhonchi sounds in lungs, and edema. Laboratory tests indicated typhoid with positive Widal test for Salmonella typhi and paratyphi. The patient was diagnosed with typhoid fever and hospitalized for IV antibiotics and supportive care.

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    morning report

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    Mr. MR, a 24-year-old male, presented with vomiting for one week. He reported nausea after eating and fever two days prior. Previous medications provided no relief. Examination found moderate illness, rhonchi sounds in lungs, and edema. Laboratory tests indicated typhoid with positive Widal test for Salmonella typhi and paratyphi. The patient was diagnosed with typhoid fever and hospitalized for IV antibiotics and supportive care.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views5 pages

    Morport 8 Juni 2014

    Uploaded by

    Agustina Anggraeni Purnomo
    Mr. MR, a 24-year-old male, presented with vomiting for one week. He reported nausea after eating and fever two days prior. Previous medications provided no relief. Examination found moderate illness, rhonchi sounds in lungs, and edema. Laboratory tests indicated typhoid with positive Widal test for Salmonella typhi and paratyphi. The patient was diagnosed with typhoid fever and hospitalized for IV antibiotics and supportive care.

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    © All Rights Reserved
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    of 5

    Mr.

    MR, 24 YO
    Cawang
    CC : Vomit Sunday, June 8
    th
    2014, 2 PM
    Findings Assesment Therapy Planning
    Nausea
    Loss of appetite

    Patient came with vomiting since 1 week ago.The vomiting of food and
    mucus.Patient said when he eat some food, he felt nausea. Two days ago, he
    had fever. Patient already consumed lanzoprazole, donperidone, ondansentron,
    and Pantoprazol, but the complain doesnt better.

    Appearance : moderate illness, GCS E4V5M6, BP : 130/80 mmHg, PR :64 x/min,
    RR : 20x/min, T : 36C

    Eye : hyperemic conjunctiva -/-, icteric sclera -/-
    THT : normal
    Mouth : coated tongue +, tremor -
    Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O

    Thorax
    Ins : symmetric
    Pal : vocal fremitus sound symmetric
    Per : symmetric sonor sound
    Aus : basic sound of breath vesicular, wheezing -/-, ronchi +/+. Heart sound I&II
    regular, murmur -, gallop -

    Abdominal
    Ins : flat
    Aus : bowel sound 8x/min
    Pal : no tenderness, liver and spleen not palpable enlarged
    Per : no percution pain







    Extremities : warm acral, CRT < 2, edema +

    - -
    - -
    Typhoid fever
    Pro Hospitalized
    Diet : Soft
    IVFD : II RL
    I Futrolit / 24hrs
    Mm/
    Levofloxacin 1x500 mg
    Omeperazole 2x40 mg
    Ondansentron 3x1c
    - H2TL

    LAB FINDING
    Hemoglobin : 15,5 g/dl
    Hematocrit : 38,5 %
    Leukocyte : 3400 /ul
    Platelet: 175.000 /ul

    Widal test
    S. Typhose H +1/320
    S. Paratyphi A H -
    S. Paratyphi B H +1/160
    S. Paratyphi C H +1/160
    S. Typhose O -
    S. Paratyphi A O +1/160
    S. Paratyphi B O +1/160
    S. Paratyphi C O +1/160























    Findings Assessment Therapy Planning
    Appearance: moderate illness, GCS : E4V5M6, BP: 130/80 mmHg, PR :
    80 x/min (adequate,regullar) RR : 22 x/min, T: 36,5 C
    Eye : conjuntiva not pale, Sklera icteric -/-
    Ear, Nose, Throat: normal
    Neck : lymph nodes did not enlarged, venous distention -
    THORAX
    Insp : symmetric, ictus cordis (-)
    Pal : vf symmetric, ictus cordis palpable
    Per : symmetric, sonor sound
    RHB ICS V lin. sternal dext, LHB ICS V lin.
    Midclavicula sin
    Aus : vesicular rh -/-,wh -/-
    S1 single, S2 single, regular, murmur (-) gallop (-)
    ABDOMINAL
    Ins : stomach looks flat
    Ausc : bowel sounds + 4x/m,
    Palp : Pressure Pain - in epigastrium
    Undulation(-)
    Per : timpany, shifting dulness (-),
    Extremitas : warm acral, CR<2, edema
    LAB FINDING:
    Complete Perifer Blood :
    Hb : 12,3 gr/dl Leu : 9.500/ul ; Ht : 39,8%
    Unstable Angina Pectoris
    DD/ Dyspepsia
    Pro Hospitelize
    IVFD : I RL/ 24 hour
    Diit : soft meal
    Mm/
    ISDN 3x2,5mg SL
    OMZ 2x40mg IV
    Clopidogrel 1x75mg PO
    Domperidon 3x10mg PO AC 30
    minutes
    Sulcrafat 3x1C PO
    Observation 48 hours with
    serial EKG.
    Tro : 231.000/ul ; random blood sugar: 104; Troponin T -; CPK 140;
    CKMB 26; ureum 28; creatinin 0,85

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