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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
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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
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Findings Assessment Therapy Planning
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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
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Tro : 231.000/ul ; random blood sugar: 104; Troponin T -; CPK 140;
CKMB 26; ureum 28; creatinin 0,85