Mr.

MR, 24 YO
Cawang
CC : Vomit Sunday, June 8
th
2014, 2 PM
Findings Assesment Therapy Planning
Nausea
Loss of appetite

Patient came with vomiting since 1 week ago.The vomiting of food and
mucus.Patient said when he eat some food, he felt nausea. Two days ago, he
had fever. Patient already consumed lanzoprazole, donperidone, ondansentron,
and Pantoprazol, but the complain doesnt better.

Appearance : moderate illness, GCS E4V5M6, BP : 130/80 mmHg, PR :64 x/min,
RR : 20x/min, T : 36C

Eye : hyperemic conjunctiva -/-, icteric sclera -/-
THT : normal
Mouth : coated tongue +, tremor -
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O

Thorax
Ins : symmetric
Pal : vocal fremitus sound symmetric
Per : symmetric sonor sound
Aus : basic sound of breath vesicular, wheezing -/-, ronchi +/+. Heart sound I&II
regular, murmur -, gallop -

Abdominal
Ins : flat
Aus : bowel sound 8x/min
Pal : no tenderness, liver and spleen not palpable enlarged
Per : no percution pain







Extremities : warm acral, CRT < 2, edema +

- -
- -
Typhoid fever
Pro Hospitalized
Diet : Soft
IVFD : II RL
I Futrolit / 24hrs
Mm/
Levofloxacin 1x500 mg
Omeperazole 2x40 mg
Ondansentron 3x1c
- H2TL

LAB FINDING
Hemoglobin : 15,5 g/dl
Hematocrit : 38,5 %
Leukocyte : 3400 /ul
Platelet: 175.000 /ul

Widal test
S. Typhose H +1/320
S. Paratyphi A H -
S. Paratyphi B H +1/160
S. Paratyphi C H +1/160
S. Typhose O -
S. Paratyphi A O +1/160
S. Paratyphi B O +1/160
S. Paratyphi C O +1/160























Findings Assessment Therapy Planning
Appearance: moderate illness, GCS : E4V5M6, BP: 130/80 mmHg, PR :
80 x/min (adequate,regullar) RR : 22 x/min, T: 36,5 C
Eye : conjuntiva not pale, Sklera icteric -/-
Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention -
THORAX
Insp : symmetric, ictus cordis (-)
Pal : vf symmetric, ictus cordis palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : vesicular rh -/-,wh -/-
S1 single, S2 single, regular, murmur (-) gallop (-)
ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 4x/m,
Palp : Pressure Pain - in epigastrium
Undulation(-)
Per : timpany, shifting dulness (-),
Extremitas : warm acral, CR<2, edema
LAB FINDING:
Complete Perifer Blood :
Hb : 12,3 gr/dl Leu : 9.500/ul ; Ht : 39,8%
Unstable Angina Pectoris
DD/ Dyspepsia
Pro Hospitelize
IVFD : I RL/ 24 hour
Diit : soft meal
Mm/
ISDN 3x2,5mg SL
OMZ 2x40mg IV
Clopidogrel 1x75mg PO
Domperidon 3x10mg PO AC 30
minutes
Sulcrafat 3x1C PO
Observation 48 hours with
serial EKG.
Tro : 231.000/ul ; random blood sugar: 104; Troponin T -; CPK 140;
CKMB 26; ureum 28; creatinin 0,85