morpot kel 2 tanggal 25 des

8/18/2019 Morpot Kel 2 Tanggal 25 Des

1/12

MORNING REPORT

Department of Internal

MedicineChristian University of Indonesia

December 25th 2015TEAM 2


2/12

Findings Assesment Therapy

• Typhoid fever

GCS: E4V5M6, TD: 120/80, PR : 86, T : !8,2 oC, RR: 20

Eye : P"#e Co$%&$'(iv" )/), S*#er" i*(eri* )/)

RPD: )

T+T : or-"#

e*. : y-ph ode $o( E$#"r'ed

VP : vein not distended

THRORAX

I : i$(er*o("# re(r"*(io$ "$d -ove-e$( i-e(ri*P"#: Vo*"# fre-i(& i-e(ri*

Per: ri'h( #&$')o$or , #ef( #&$')o$or

&: 3"i* re"(h o&$d vei*er , ro$*hi )/), heei$' )/)7

S1 "$d S2 re'er, '"##op )9, -&r-&r )9

ABDOMEN

$ : f#"(

& : 3oe# o&$d ;9 4/-i$&(e

P"# : Pre&re p"i$ ;9, liver and spleen enlargement

(-

Per : (y-p"$i, per!"ssion tenderness (#

Extremitas : oede-" )9, "r- "*r"#, CRT < 2=, (&r'or

$or-"#

Typhoid fever MM:

evof#o"*i$ 500-' 11 iv9

S"$-o# 500-' !1

Do-perido$e 10-' !1

S&*r"#f"( !1 C

>-epr"o#e 40 -' 11 iv9

37 Co-p 11

)Pro r"

)V?D

"-

)die( $

Miss A / 2 !O

"" # Typh$id %e&er


3/12

Subjective DataName $ Miss %& ' years old

TC $ )riday& *e!em+er ',th '.,


4/12

AnamnesisMain smptom $ Typhoid fever

Additional smptom $ -

The patient !ame to IG* R/U U0I 1ith !omplaints

pain in the 1hole +ody sin!e ' days ago s"!h as a

sense of +eing sta++ed2 The !omplain felt!o"ntino"sly2 Patient also felt fever and shiver& fever

"p and do1n& high in the evening and go do1n inthe morning sin!e 3 days ago2 4istory of tra"ma (-&

)ever (#& Na"sea (#& vomitting (#& de!rease in

1eight (-2


5/12

Past Medi!al 4istory and Treatment

(-)

)amily 4istory

(-)

/o!ial 4istory(-)


6/12

!bjective Data

• %ppearan!e $ Moderate Illness

• GC/ EM56,

• 7P $ .'89 mmhg&

• RR$ ':8 min"te&

• T $ 39&';C

• P"lse $ 95 :8min"te2

• Eye$ Pale !on


7/12

• Thora: – I : i$(er*o("# re(r"*(io$ "$d -ove-e$( i-e(ri* – P"#: Vo*"# fre-i(& i-e(ri*, #o

– Per: ri'h( #&$') o$or, #ef( #&$')o$or

– &: 3"i* re"(h o&$d vei*er , ro$*hi )/), heei$' )/)7 S1 "$d S2 re'er, '"##op

• %+domen2 – I $ >at – %"s $ +o1el so"nd (# :8min"te

– Per $timpani& per!"ssion tenderness (# – Pal $ a+dominal tenderness (#& liver and spleen enlargement

• E:tremity- ?arm a!ral- Capillary re@lling time A' se!ond- Edema (-- T"rgor normal


8/12

Clini!al Ba+oratory

• Th"rsday& '3 ="ly '.,

• 4ematologi – 4emoglo+in $ .,&3 gr8dl

– Be"osit $ .3&5 r+8"l

– 4ematorit $ ,& D

– Trom+osit $ 3. r+8"l

– Natri"m .. mmol8B

– 0ali"m$ 3&. mmol8B

– Clorida$ 9 mmol8B

– G*/ $ .,,

– Ure"m $39 Creatinin &3

Agd :•Ph darah 7, 462•PCO2 41,8•po2 93,5•Saturasi O2 97,7•as! a"s!s 6,3

•#CO3 3$,1•%"o2 31,4•&o's!'trasi O2 2$,9


9/12

Assessment

Typhoid Fever


10/12

TherapMM:

evof#o"*i$ 500-' 11 iv9

S"$-o# 500-' !1

Do-perido$e 10-' !1

S&*r"#f"( !1 C

>-epr"o#e 40 -' 11 iv9

37 Co-p 11


11/12

"lannin#

)Pro r""( i$"p

)V?D R/24 "- @ f&(ro#i(/24 "-

)die( $"i (i-


12/12

Than$ %ou

Department of Internal

MedicineChristian University of Indonesia

morpot kel 2 tanggal 25 des

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