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  • Team 4 Morpot

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    Putri Lastiana
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    Mr. Parlindungan S, a 45-year-old male, was admitted to the hospital with a chief complaint of headache and nausea for the past week. A physical examination showed he was moderately sick with normal vital signs. Laboratory tests confirmed a diagnosis of typhoid fever as the Widal test was positive for Salmonella Typhi O and Paratyphi C. The treatment plan was for the patient to remain hospitalized, receive a bland diet and IV fluids, and be given medications including paracetamol, ciprofloxacin, domperidone, and ranitidine.

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    Mr. Parlindungan S, a 45-year-old male, was admitted to the hospital with a chief complaint of headache and nausea for the past week. A physical examination showed he was moderately sick with normal vital signs. Laboratory tests confirmed a diagnosis of typhoid fever as the Widal test was positive for Salmonella Typhi O and Paratyphi C. The treatment plan was for the patient to remain hospitalized, receive a bland diet and IV fluids, and be given medications including paracetamol, ciprofloxacin, domperidone, and ranitidine.

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    13 views3 pages

    Team 4 Morpot

    Uploaded by

    Putri Lastiana
    Mr. Parlindungan S, a 45-year-old male, was admitted to the hospital with a chief complaint of headache and nausea for the past week. A physical examination showed he was moderately sick with normal vital signs. Laboratory tests confirmed a diagnosis of typhoid fever as the Widal test was positive for Salmonella Typhi O and Paratyphi C. The treatment plan was for the patient to remain hospitalized, receive a bland diet and IV fluids, and be given medications including paracetamol, ciprofloxacin, domperidone, and ranitidine.

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    © All Rights Reserved
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    of 3

    Team 4

    Morning Report

    IDENTITY OF THE PATIENT

    Name

    : Mr. Parlindungan S

    Age

    : 45 years old

    Sex

    : Male

    Admission date : 11-10-2016

    Status

    : Hospitalized

    ANAMNESIS

    Chief Complaint

    Chronological order:

    : Headache and Nausea

    The patient came to the hospital with a chief complaint of headache, nausea, and
    vomiting since 1 week ago. These complaint lasts continously. The patient already went to see
    a doctor and hospitalized for 4 days, but the complaints are not going better. When the patient
    hospitalized, he was diagnosed typhoid fever. The appetite still good, fever (-), urinate and
    defecate is normal.
    PHYSICAL EXAMINATION

    General condition

    : Moderately sick

    Awareness

    : E4M6V5 (Composmentis)

    Blood Pressure : 130/80 mmHg

    Heart Rate

    : 80 x/minute

    Respiratory Rate

    : 18 x/minute

    Temp.

    : 36.20C

    Head

    : Normocephali

    Eyes

    : Anemic conjunctiva -/-, ichteric sclerae -/-

    Neck

    Chest :

    : No lymph node enlargements

    Inspection

    : Symmetrical respiratory movements, no uneven rib movement

    Palpation

    : Symmetrical vocal fremitus

    Percussion

    : Sonor sounds all over lung platforms

    Auscultation:

    Lung Vesicular, Ronchi -/-, Wheezing -/-

    Heart Normal, murmur (-), Gallop (-)

    Abdomen

    Inspection: appeared flat

    Auscultation: Intestinal sounds + 4x/min

    Palpation: Pressure pain -, release pain -

    Percussion: tympanic, percussion pain -

    Extremity: warm acrals, CRT < 2, Oedema -/-

    LABORATORY

    Hemoglobin

    : 15,0 g/dl

    Leukocyte

    : 6.900/uL

    Hematocrit

    : 45,1%

    Trombocyte

    : 309.000/uL

    Widal Test

    S. Typhose H

    S. Paratyphi A H

    :(-)

    S. Paratyphi B H

    :(-)

    S. Paratyphi C H

    :(-)

    : ( + ) 1/160

    S. Typhose O

    S. Paratyphi A O

    :(-)

    S. Paratyphi B O

    :(-)

    S. Paratyphi C O

    : ( + ) 1/320

    : ( + ) 1/160

    DIAGNOSIS

    Typhoid Fever

    THERAPY PLANS

    Pro Hospitalised

    Diet: Bland, low fiber 2100 kilocalories

    IVFD: II RL + I Futrolite

    Mm/

    Paracetamol 3 x 500 mg (PO)

    Ciprofloxacin 2 x 200 mg (IV)

    Domperidone 3 x 10 mg (PO)

    Ranitidine 2 x 1 amp (IV)

    B Complex 2 x 1 tab (PO)

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