MORNING REPORTDepartment of Internal MedicineChristian University of IndonesiaFriday, April 3th 2015 TEAM 1

Mrs. E, 37 YOCC :

FindingsAssesmentTherapyPlanningWatery stool 3 times since about 8 hours ago.Dry cough, nausea, vomitus, headache GCS: E4V5M6, TD: 120/80, PR 78x, T : 37oC, RR: 24xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : FlatAus : Bowel sound (+) 4x/minutePal : Pressure pain (+) on hypocondrica sinistraPer : tympaniExtremitas : pitting oedem (-), warm acral, CRT < 2, turgor normal Typhoid FeveriVFD : 1 RL/24 hourMM/Ondancentrone 1 x 8mgPro HospitalizeDiet : soft not do not stimulateCheck lab : H2TL, GDS, Widal TestMM: Ciprofloxacine1 x 500mg Domperidone 2 x 1 tab Novalgin k/p Paracetamol k/p

Subjective DataName: Mrs. ETC: Friday, April 3th 2015CC :

AnamnesisMain symptom : watery stool Additional symptom : Dry cough, nausea, vomitus, headache

Patient came to UKI hospital with watery stool 3 times since about 8 hours ago. Feces dregs (-), mucose (-), blood (-). And then, pasien had dry coughed, , nausea, vomitus, and headache and never been treated before.The patient has experienced the same symptomps.

Past Medical History and Treatment Hypertension gr.I

Family Historydenied

Social HistorySmoking denied

Objective DataAppearance : Moderate IllnessGCS E4M6V5BP : 120/80 mmhg, RR: 24x/ minute, T : 37CPulse : 78 x/minute.Eye: Pale conjunctiva -/- , sclera icteric -/-Ear, Nose, throat : normalJVP : not distended

Thorax. I : symmetrical, non-visible ictus cordisPal: symmetrical vocal fremitus, ictus cordis : unpalpablePer: Sonore, cardiac englargement (-)Aus: Basic breath sound vesicular, ronchi -/-, wheezing -/-. Normal heart sound, gallop (-), murmur (-) Abdomen.I : flatAus : bowel sound (+) 4x/minutePer : timpani, percussion tenderness (-)Pal : abdominal tenderness (+) on hypocondrica sinistra, liver and spleen enlargement (-)ExtremityWarmCapillary refilling time

Clinical LaboratoryH2TL:Hb : 12,5 g/dLLeu : 8,8 ribu/uLHt : 38,9 %Trombosit : 310 ribu/uLWidal Test

GDS : 116 mg/dl

Assessment Typhoid Fever

TherapyIVFD : I RL/24hourDrugs:Ondancentrone 1 x 8 mg

Planning

Pro hospitalizeDiet soft do not stimulateH2TL, Widal Test, GDSMM : Ciprofloxacin1 x 500 mg (IV)Domperidone 2 x 1 tabNovalgin k/pParacetamol k/p

Thank YouDepartment of Internal MedicineChristian University of Indonesia

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