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  • POMR 5. Typhoid

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    Alvin Pratama
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    Mr. M, a 50-year-old man, presented with fever for 5 days, abdominal pain, nausea, vomiting, and weakness. On examination, he appeared ill and lethargic with a fever of 38.5°C, mild dehydration, and fine skin turgor. Laboratory tests showed leukocytosis and a positive Widal test. Based on the presentation and test results, the working diagnoses were typhoid fever, dengue fever, acute hepatitis, or chikungunya. The patient was given intravenous fluids, antibiotics, antiemetics, and paracetamol and monitored for vital signs, blood counts, and complaints.

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    demam tifoid

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    Mr. M, a 50-year-old man, presented with fever for 5 days, abdominal pain, nausea, vomiting, and weakness. On examination, he appeared ill and lethargic with a fever of 38.5°C, mild dehydration, and fine skin turgor. Laboratory tests showed leukocytosis and a positive Widal test. Based on the presentation and test results, the working diagnoses were typhoid fever, dengue fever, acute hepatitis, or chikungunya. The patient was given intravenous fluids, antibiotics, antiemetics, and paracetamol and monitored for vital signs, blood counts, and complaints.

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    44 views3 pages

    POMR 5. Typhoid

    Uploaded by

    Alvin Pratama
    Mr. M, a 50-year-old man, presented with fever for 5 days, abdominal pain, nausea, vomiting, and weakness. On examination, he appeared ill and lethargic with a fever of 38.5°C, mild dehydration, and fine skin turgor. Laboratory tests showed leukocytosis and a positive Widal test. Based on the presentation and test results, the working diagnoses were typhoid fever, dengue fever, acute hepatitis, or chikungunya. The patient was given intravenous fluids, antibiotics, antiemetics, and paracetamol and monitored for vital signs, blood counts, and complaints.

    Copyright:

    © All Rights Reserved
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    of 3

    POMR (Problem Oriented Medical Record)

    Name
    Age
    Address
    Religion

    : Mr. M
    : 50 years old
    : Jl. Prof M. Yamin
    : Islam

    SUMMARY
    OF DATA BASE (SUBJECTIVE)
    Identitas
    Mr. M ,50 years old
    Anamnesis
    Chief Complaint: Fever
    History of Present Illness:
    a) Fever since 3 days, not affected by paracetamol
    b) Fever felt all day
    c) Chilling
    d) Nausea and Vomit since 1 day ago
    e) Abdominal pain since 1 day ago
    f) Muscle stiffness in back
    g) Joint pain

    OBJECTIVE

    General Physical
    Examination
    General appearance: look ill
    and letargis.
    Concioussness : compos
    mentis
    GCS: 456
    BP : 80/70 mmHg
    HR : 90 x/minute
    RR: 22 x/minute
    T : 38,5 oC
    BW : 50 kg

    CLUE AND CUE


    PROBLEM
    LIST
    - Febris
    Fever since 5 days,
    - Abdominal pain
    not affected by
    - Leukositosis
    paracetamol
    - Widal (+)
    Fever felt all day
    Headache and
    Chilling
    Nausea and Vomit
    4x since 1 day ago
    Abdominal pain
    since 1 day ago
    Weakness after
    vomit
    Leukositosis
    Widal (+)

    WORKING DX
    DIAGNOSIS
    - Typhoid Fever
    - Acute Viral Infection:
    1. DHF (grade 1)
    2. Typhoid fever
    3. Acute Hepatitis
    4. Chikungunya

    History of Past Illness:


    - No previous similar complaint
    - Hypertension (-), DM (-), Asthma (-)
    Family History:
    - No similar complaint
    Personality and Social History
    - Smoking
    - No traveling

    Spesific Physical Exam


    Head and Facial:
    Anemis (-)
    Ikterik (-)
    Cyanosis (-)
    Dyspneu (-)
    Dry Lips
    Neck : Lymphonodi
    enlargment (-)

    - Fine Turgor
    - Dry lips

    - Dehydration

    - Mild Dehydration e.c


    febris

    Tubex test
    IgM Dengue
    IgM HAV
    IgM HEV
    HbsAg

    PLANNING
    THERAPY

    MONITORING

    - RL 500 cc 30
    drop/min
    - Cefotaxime Inj
    2x1gr
    - Omeprazole Inj
    - Ondansentron
    Inj 3x4mg
    - PCT 3x500mg

    - Vital Sign
    - Hb, Hct,
    Trombosit
    every 24 hours
    - Patient
    complaint
    - Consul to
    Internist

    No DHF cases in neighborhood


    Lungs:
    Inspection :
    Symmetrical breathing
    movement
    palpation Normal
    and symmetrical fremitus
    Percussion : Sonor
    Auscultation vesiculer,
    ronki -/-, wheezing -/Heart:
    Inspection Iktus cordis
    not visible
    Palpation Thrill not
    palpable,
    Percussion Normal
    heart size
    Auscultation Single
    S1- S2 reguler, murmur
    (-), gallop (-)
    Abdomen:
    Inspection flat.
    Palpation tenderness (), hepatomegali (-),
    splenomegali (-), mass (), normal skin turgor
    Auscultation normal
    gut sound, meteorismus
    (-)
    Percussion timpani,
    shifting dullness (-)
    Extremity: Cold akral;
    CRT<2dtk, ptekie (-),
    Rumple leed (-).

    Lab Exam
    CBC:
    HB: 15,4 gr /dl
    Leu: 12,7 (10^3/uL)
    Trombo : 40 (10^3/uL)
    Hematokrit:
    44,5 %
    ECG:
    Sinus Tachycardia HR
    119x/min with
    Inferiolateral ST
    Elevation

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