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