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    Morning Report: Supervisor: Dr. Hildebrand Hanoch W., SPPD

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    Hilda Muda
    This document summarizes a patient medical report from a hospital in Indonesia. It includes details about a 19-year-old female patient named Rosidah who presented with fever, vomiting, nausea, malaise and dizziness. Upon examination, her temperature was 38.5C and her abdomen was tender. Laboratory tests found an elevated white blood cell count and positive results for Salmonella Typhi and Paratyphi in her blood. The working diagnosis was typhoid fever. The treatment plan was to hospitalize her, provide IV fluids and medications including levofloxacin, omeprazole and ondansetron to manage her symptoms.

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    Morning Report: Supervisor: Dr. Hildebrand Hanoch W., SPPD

    Uploaded by

    Hilda Muda
    21 views11 pages
    This document summarizes a patient medical report from a hospital in Indonesia. It includes details about a 19-year-old female patient named Rosidah who presented with fever, vomiting, nausea, malaise and dizziness. Upon examination, her temperature was 38.5C and her abdomen was tender. Laboratory tests found an elevated white blood cell count and positive results for Salmonella Typhi and Paratyphi in her blood. The working diagnosis was typhoid fever. The treatment plan was to hospitalize her, provide IV fluids and medications including levofloxacin, omeprazole and ondansetron to manage her symptoms.

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    Morning Report 07-06-16

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    This document summarizes a patient medical report from a hospital in Indonesia. It includes details about a 19-year-old female patient named Rosidah who presented with fever, vomiting, nausea, malaise and dizziness. Upon examination, her temperature was 38.5C and her abdomen was tender. Laboratory tests found an elevated white blood cell count and positive results for Salmonella Typhi and Paratyphi in her blood. The working diagnosis was typhoid fever. The treatment plan was to hospitalize her, provide IV fluids and medications including levofloxacin, omeprazole and ondansetron to manage her symptoms.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    21 views11 pages

    Morning Report: Supervisor: Dr. Hildebrand Hanoch W., SPPD

    Uploaded by

    Hilda Muda
    This document summarizes a patient medical report from a hospital in Indonesia. It includes details about a 19-year-old female patient named Rosidah who presented with fever, vomiting, nausea, malaise and dizziness. Upon examination, her temperature was 38.5C and her abdomen was tender. Laboratory tests found an elevated white blood cell count and positive results for Salmonella Typhi and Paratyphi in her blood. The working diagnosis was typhoid fever. The treatment plan was to hospitalize her, provide IV fluids and medications including levofloxacin, omeprazole and ondansetron to manage her symptoms.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 11

    MORNING REPORT

    Supervisor:
    dr. Hildebrand Hanoch W., SpPD

    Internal Medicine Department


    Period of 9 May 2016 24 July 2016
    Faculty of Medicine
    Christian University of Indonesia

    Patients Identity
    Name

    : Nn. Rosidah
    Sex
    : Female
    Age
    : 19 years old
    Occupational : Religion
    : Moeslem
    Education :
    Address
    : Cawang Jakarta Timur
    Entry date : 07/06/2016

    ANAMNESIS
    Auto / Allo

    : Autoanamnesis

    Date

    : 07/06/2016

    Main complaint

    : Fever

    Additional complaints: Vomit, Nausea, Malaise, Dizzy.

    HISTORY
    Patient came with intermitten fever about 3 days, the
    fever mostly rising in the evening. In addition, patients
    also complained vomiting (+) 3x, Nausea, Malaise and
    dizzy, and lose of appetite, patient havent get any
    medication.

    PAST MEDICAL HISTORY:

    Hypertension (-), DM (-), Asthma (-)

    Pemeriksaan Fisik
    General Situation

    Looked moderate ill being

    Awareness

    Composmentis

    GCS

    E4M6V5

    Blood pressure

    130/90

    Pulse

    80x/m

    RR

    20x/m

    Temperature

    38,5C

    Head

    Normocephali ; CP : -/- ; SI : -/-

    Neck

    Lymph nodes not enlarged, Distended Vena jugular (-)

    Thorax

    I: Symmetric chest wall movement left = right


    P: Symmetric vocal fremitus
    P: Symmetric sonor
    A: Basic breath sound vesicular, rh +/+, wh -/-, heart sound 1
    & 2 regular, murmur (-), gallop (-)

    Abdomen

    I
    A
    P
    P

    Extremities

    cold, CRT <2, edema - --

    : Looks big
    : Bowel sounds (+) 4x/minute
    : Tympani, pain (-)
    : supple, Tenderness (+) in supra pubic

    Pemeriksaan Penunjang
    Laboratory :
    H2TL :
    Hemoglobin:13,8 g/dl
    Leukosit
    : 4.6 ribu/ul
    Hematokrit :42.3 %
    Trombosit : 222 ribu/ul
    Widal Test
    S. Typhose H

    (+) 1/80
    S. Paratyphi A H
    negatif
    S. Paratyphi B H
    negatif
    S. Paratyphi C H
    negatif
    S. Typhose O (+) 1/160
    S. Paratyphi A O
    negatif
    S. Paratyphi B O
    (+) 1/160
    S. Paratyphi C O (+) 1/80

    Working Diagnosis
    Thypoid fever

    Therapy
    Hospitalize
    Diet : Soft
    IVFD : III RL/ 24 jam
    MM/
    Levofloxacine 1x500mg (po)
    Omeprazole 1x40mg (IV)
    Sanmol 3x1 (po)
    Ondancetron 2x4mg (IV)

    THANK YOU

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