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    Morpot Kel 2 Tanggal 25 Des

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    Ella AnggRaini
    1. A 24-year-old female patient presented with complaints of fever, body aches, and nausea for the past few days. Examination findings included a temperature of 38.2°C, pale conjunctiva, abdominal tenderness, and enlarged liver and spleen. 2. Laboratory tests showed elevated white blood cell count. The assessment was typhoid fever. 3. The treatment plan included intravenous levofloxacin, antacids, and IV fluids. The patient was admitted for inpatient care with monitoring of IV fluids and diet.

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    Morpot Kel 2 Tanggal 25 Des

    Uploaded by

    Ella AnggRaini
    20 views12 pages
    1. A 24-year-old female patient presented with complaints of fever, body aches, and nausea for the past few days. Examination findings included a temperature of 38.2°C, pale conjunctiva, abdominal tenderness, and enlarged liver and spleen. 2. Laboratory tests showed elevated white blood cell count. The assessment was typhoid fever. 3. The treatment plan included intravenous levofloxacin, antacids, and IV fluids. The patient was admitted for inpatient care with monitoring of IV fluids and diet.

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    1. A 24-year-old female patient presented with complaints of fever, body aches, and nausea for the past few days. Examination findings included a temperature of 38.2°C, pale conjunctiva, abdominal tenderness, and enlarged liver and spleen. 2. Laboratory tests showed elevated white blood cell count. The assessment was typhoid fever. 3. The treatment plan included intravenous levofloxacin, antacids, and IV fluids. The patient was admitted for inpatient care with monitoring of IV fluids and diet.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    20 views12 pages

    Morpot Kel 2 Tanggal 25 Des

    Uploaded by

    Ella AnggRaini
    1. A 24-year-old female patient presented with complaints of fever, body aches, and nausea for the past few days. Examination findings included a temperature of 38.2°C, pale conjunctiva, abdominal tenderness, and enlarged liver and spleen. 2. Laboratory tests showed elevated white blood cell count. The assessment was typhoid fever. 3. The treatment plan included intravenous levofloxacin, antacids, and IV fluids. The patient was admitted for inpatient care with monitoring of IV fluids and diet.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    of 12

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT
    December 25th 2015
    TEAM 2

    Miss A / 24 YO
    CC : Typhoid fever
    Findings
    Typhoid fever
    GCS: E4V5M6, TD: 120/80, PR : 86x, T : 38,2oC, RR: 20x
    Eye : Pale Conjungtiva -/-, Sclera icteric -/RPD: THT : Normal
    Neck : Lymph Nodes not Enlarged
    JVP : vein not distended
    THRORAX

    : intercostal retraction and movement simetric


    Pal: Vocal fremitus simetric
    Per: right lung-sonor , left lung-sonor
    Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-.
    S1 and S2 reguler, gallop (-), murmur (-)
    ABDOMEN
    Ins : flat
    Aus : Bowel sound (+) 4x/minute
    Pal : Pressure pain (+), liver and spleen enlargement
    (-)
    Per : tympani, percussion tenderness (+)
    Extremitas : oedema (-), warm acral, CRT < 2, turgor
    normal

    Assesment
    Typhoid fever

    Therapy
    MM:
    Levofloxacin 500mg 1x1 (iv)
    Sanmol 500mg 3x1
    Domperidone 10mg 3x1
    Sucralfat 3x1 C
    Omeprazole 40 mg 1x1 (iv)
    B. Comp 1x1

    Planning
    -Pro rawat inap
    -IVFD I RL/24 Jam ; II futrolit/24
    Jam
    -diet nasi tim

    Subjective Data
    Name
    TC

    : Miss A, 24 years old


    : Friday, December 25th 2015

    Anamnesis
    Main symptom
    Additional symptom

    : Typhoid fever
    :-

    The patient came to IGD RSU UKI with complaints


    pain in the whole body since 2 days ago such as a
    sense of being stabbed. The complain felt
    countinously. Patient also felt fever and shiver, fever
    up and down, high in the evening and go down in
    the morning since 3 days ago. History of trauma (-),
    Fever (+), Nausea (+), vomitting (+), decrease in
    weight (-).

    Past Medical History and Treatment


    (-)

    Family History

    (-)
    Social History
    (-)

    Objective Data

    Appearance : Moderate Illness


    GCS E4M6V5
    BP : 120/80 mmhg,
    RR: 20x/ minute,
    T : 38,2C
    Pulse : 86 x/minute.
    Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
    JVP : vein not distended

    Thorax
    I

    : intercostal retraction and movement simetric


    Pal: Vocal fremitus simetric, low
    Per: right lung- sonor, left lung-sonor
    Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

    Abdomen.

    I : flat
    Aus : bowel sound (+) 4x/minute
    Per :timpani, percussion tenderness (+)
    Pal : abdominal tenderness (+), liver and spleen enlargement (-)

    Extremity
    -

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

    Clinical Laboratory
    Thursday, 23 July 2015
    Hematologi

    Hemoglobin : 15,3 gr/dl


    Leukosit : 13,6 rb/ul
    Hematokrit : 45,4 %
    Trombosit : 314 rb/ul
    Natrium 141 mmol/L
    Kalium: 3,1 mmol/L
    Clorida: 98 mmol/L
    GDS : 155
    Ureum :38 Creatinin 0,93

    Agd :
    Ph darah 7, 462
    PCO2 41,8
    po2 93,5
    Saturasi O2 97,7
    Base acses 6,3
    HCO3 30,1
    Tco2 31,4
    Konsentrasi O2 20,9

    Assessment
    Typhoid Fever

    Therapy
    MM:
    Levofloxacin 500mg 1x1 (iv)
    Sanmol 500mg 3x1
    Domperidone 10mg 3x1
    Sucralfat 3x1 C
    Omeprazole 40 mg 1x1 (iv)
    B. Comp 1x1

    Planning
    -Pro rawat inap
    -IVFD I RL/24 Jam ; II futrolit/24 Jam
    -diet nasi tim

    Department of Internal
    Medicine
    Christian University of Indonesia

    Thank You

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