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MORNING

REPORT
Department of Internal Medicine
Christian University of Indonesia
May, 24
th
2014
TEAM 1
Mr. Sutisna, 36 years Saturday, May 24
th
2014, 17:13:51 PM
Findings Assesment Therapy Planning
Headache since 5 days before admission
Intermittent fever since 10 days before admission
Decreased appetite
Nausea
Epigastric pain
PHYSICAL EXAMINATION
Appearance : being sick, GCS E4V5M6
Awareness: Composmentis, BP : 80/50 mmHg, HR : 88x/min,
RR : 20x/min, T : 38,2C
Head: Normocephaly
Eye : pale conjunctiva -/-, icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O
Thorax
Ins : symmetric
Pal : vocal fremitus sound symmetric
Per : sonor right = left
Aus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)
Heart : Heart sound I & II regular, murmur (-), gallop (-)
Abdominal
Ins : flat
Aus : bowel sound 6x/min
Per : no percution pain, timpany
Pal : supel, tenderness (+)
Typhoid fever
Dyspepsia
Pro Hospitalized
Diet: Tim rice
IVFD : III RL 24/ hours
Mm/
Levofloxacin tab 1x500mg
Analsik 3x1
Omerprazole cap 2x1
Sucralfat syr 3x2
Theragram M 1x1
Alprazolam tab 0,5 mg 3x1
Laboratorium :
Blood H2TL
Widal test
Mr. Sutisna, 36 years Saturday, May 24
th
2014, 17:13:51 PM
Findings
Extremities
warm acral, CRT < 2 s, edema -/-
LAB FINDING
-H2TL:
Hemoglobin : 12,7g/dl
Haematocrite : 36,5 %
Leucocyte: 5.900 /ul
Thrombocyte :215.000 /ul
-WIDAL TEST:
S. typhose H : (+) 1/160
S. Paratyphi A H : (+) 1/80
S. Paratyphi B H : (+) 1/160
S. Paratyphi C H : NEGATIF
S. Typhose O : (+) 1/320
S. Paratyphi A O : NEGATIF
S. Paratyphi B O (+) 1/80
S. Paratyphi C O : NEGATIF
Subjective Data
Name : Mr. Sutisna
CM :
TC : Saturday , May 24
th
2014
CC : Headache

Anamnesis
Main symptom : Headache
Additional symptom : Intermittent fever , decreased appetite, nausea
epigastric pain.

Patient came to UKIs hospital with headache about 5 days ago before
entering the hospital. Headache was felt continously and stabbing. Before that, the
patient felt the intermittent fever about 1 weeks. The patient has gone to the clinic
for treatment , and get the medicines (paracetamol, cefixime, and ranitidin) but the
symptom is not healed. The patient adding he also decreased appetite, nausea and
epigastric pain. For the defecate and urinate are no complaints.

Past Medical History and Treatment
Typhoid fever

Family History
Denied

Social History
Eating carelessly
Objective Data
Appearance : being sick
GCS E4M6V5
Awareness : composmentis
BP : 80/50 mmHg
RR: 20x/minute
T : 38,2C
HR : 88x/minute
Eyes: Pale conjunctiva (-/-) , sclera icteric -/-
Ears, Nose, Throat : normal
Mouth : normal
Neck : lymph nodes not enlarge
JVP : 5-2 cmH2O


Thorax
Ins : symmetric
Pal : vocal fremitus sound symmetric
Per : sonor right = left
Aus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)

Heart : Heart sound I & II regular, murmur (-), gallop (-)

Abdominal
Ins : flat
Aus : bowel sound 6x/min
Per : no percution pain, timpany
Pal : supel, tenderness (+)

Extremities
warm acral, CRT < 2 s, edema -/-


Clinical Laboratory
H2TL :
Hemoglobin : 12,7g/dl
Haematocrite : 36,5 %
Leucocyte: 5.900 /ul
Thrombocyte :215.000 /ul

WIDAL TEST :
S. typhose H : (+) 1/160
S. Paratyphi A H : (+) 1/80
S. Paratyphi B H : (+) 1/160
S. Paratyphi C H : NEGATIF
S. Typhose O : (+) 1/320
S. Paratyphi A O : NEGATIF
S. Paratyphi B O (+) 1/80
S. Paratyphi C O : NEGATIF

Assessment
Thyphoid Fever
Therapy
Pro : Hospitalization
Diet : Tim rice
IVFD : III RL / 24 hours
Mm/ Levofloxacin tab 1x500mg
Analsik 3x1
Omerprazole cap 2x1
Sucralfat syr 3x2
Theragram M 1x1
Alprazolam tab 0,5 mg 3x1


Planning

Laboratorium
Blood H2TL
Widal test