morport 8 juni 2014.docx

8/12/2019 morport 8 juni 2014.docx

1/5

Mr. MR, 24 YO

Cawang

CC : Vomit Sunday, June 8th

2014, 2 PM

Findings Assesment Therapy PlanningNausea

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 HospitalizedDiet : Soft

IVFD : II RLI Futrolit / 24hrs

Mm/

Levofloxacin 1x500 mgOmeperazole 2x40 mgOndansentron 3x1c

- H2TL


2/5

LAB FINDING

Hemoglobin : 15,5 g/dl

Hematocrit : 38,5 %

Leukocyte : 3400 /ul

Platelet: 175.000 /ul

Widal test

S. Typhose H +1/320S. 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


3/5

Findings Assessment Therapy Planning


4/5

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


5/5

Tro : 231.000/ul ; random blood sugar: 104; Troponin T -; CPK 140;

CKMB 26; ureum 28; creatinin 0,85

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morport 8 juni 2014.docx