MORNING REPORT

CASE
Februari 19, 2010
 Patient Identity
• MDAP
• Female
• 38 years old
• Hindus
• Jln. P.Saelus II No. 6A. Denpasar
• Tc : 20.30 pm
 ANAMNESIS
• Chief Complaint: Fever
– Patient complaint with fever since 2 weeks before admission to
hospital. Firstly she got sub febril fever and fever came continuesly.
Sometime fever is decrease by antipiretik but never be normal
temperature. Fever until chill was denied.
– Patient also complaint watery defecation since 3 day before admission
to the hospital. She got watery defecation about three until fours time
a day. Watery defecation is yellowish colour and no blood or mucus.
Before diarrhea, she got constipation during 2 day.
– Patient also complaint nausea since 2 weeks and worsening 2 days
before admission to hospital. She also has vomit 1 -2 times a day, ½
glass every vomit, contain food and water, there is no blood or black
colour in the vomitted materials. Vomit is worsening with meal and
her appetite become decrease.
This condition make patient daily activities disturbed. The complaint
worsening, patient still felt weak although she had rest. She also
worried about her condition will be influence her pregnant
– Cough (-), Brestlessnes (-), epistaksis (-). Urinate was normal.
 Medical History

• Patient had been check for her condition to

the doctor and got paracetamol 3 x 500 mg,
amoxicylin 3x 500 mg.
 Past history
• There is no history about same complaint.
• There is no history hipertension, DM, or
asthma.
 Family History
• None of her family have the same complain
 Social Economy history
• Patient is a housewife, no smoking and no
alcohol consuming.
• Going to endemic malaria was denied.
 Obstetric History
• HPHT : 01/09/2009
• TP : 08/06/2010
• Abdominal pain (-), amnion discharge (-) fetal
movement (+) normal.
 Physical Examination
• GC : moderately ill
• LOC : Compos Mentis (E4V5M6)
• BP : 100/60 mmHg
• Resp : 20 x/mnt
• Pulse rate : 80 x/mnt
• Tax : 39,00 C
• Eye : an +/+, ikt -/-, rp +/+, eyelid swollen +/+
• ENT : Typhoid tongue (+)
• Neck : Lymph node enlargement (-)
• Thorax :
Cor : I : IC Unseen
Pal : IC unpalpable
Per : RB : PSL D
LB : MCL S ICS V
UB: ICS II
Aus: S1S2 single,reguler, Murmur(-)
Lung: I : Simetris
Pa : VF N/N
Per: sonor /sonor
A : Ves +/+, Rh -/- , Wh -/-

Abdomen : I : enlarge
Aus : BS (+) N
Pa : H/L unpalpable
Pe : thympani

• Extremeties : Warm + + Oedem - -

+ + - -
 Obstetric examination
• Fundus uteri 2 finger upper umbilicus
• FHB : 12.12.12
 Lab
CBC WIDAL
WBC : 7,8
Neu : 5,8 Salmonella Typhi H : 1/320
Lym : 8,9 Salmonella Typhi O : 1/320
HGB : 10,9 Paratyphi AO : 1/320
HCT : 30,6 Paratyphi BO : 1/160
PLT : 263 Paratyphi CO : 1/320
 Assesment
• Susp Typhoid Fever (Febris 15th day)
• G2P1001, 24 -25 week S/L.
 Therapy
• Hospitalized
• RL 20 drop/mnt
• Ceftriaxon 2 x 1 gr (iv)
• Paracetamol 3 x 500 mg
• Consul Obgyne
 Planning
Pdx : - Gall Cultur

Mx: - Complaint
- VS
THANKS YOU