Lapjag Igd 9 Maret

8/19/2019 Lapjag Igd 9 Maret

1/20

DUTY REPORT

09 March 2016

GP on duty : dr. Vira & dr. Ike

Coass on duty : Aisyah, Handelia, Kiki


2/20

PATIENTS RECAPITULATION

Total : 25 patients


3/20

PATIENT’S IDENTITY

!a"e : #s. PA Pla$e & %ate o 'irth : 25 (une )**5

A+e : 2 years old -$$upation : tudent /eli+ion : #osle" #arital tatus : in+le Address : 'ekasi %ate o ad"ission : * #ar$h 2)0


4/20

HISTORY TAKING

Chief complaint : 1eer sin$e 3 days a+o.

3


5/20

His!r" !# Pr$s$% I&&%$ss

History of Present Illness :

Patient $a"e to the e"er+en$y roo" 4ith $hie $o"plaint o eer

our days eore ad"ission. 1eer in$reased +radually and eltparti$ularly in the eenin+. Patient also $o"plainin+ aoutnausea and o"itin+. he o"ited 6 ti"es, $ontained ood and

4ater, 4ith olu"e 7 8 "l. Heada$he 9;, 4eakness 9;,

$onstipation 9; sin$e 3 days a+o.

Patient $onsu"ed para$eta"ol ut there is no i"proe"ent. hedid not $o"plain aout red spots, spontaneous leedin+,


6/20

His!r" !# Pas I&&%$ss

!o history o diaetes, hypertension, kidney, heart, andlun+ diseases

He neer e>perien$ed these sy"pto"s eore


7/20

His!r" !# #a'i&" i&&%$ss !o history o diaetes, hypertension, kidney,

heart, and lun+ diseases

!o a"ily "e"ers hae the si"ilar sy"pto"s


8/20

Ph"sica& E(a'i%ai!%

General tate : #oderate illness Cons$iousness : 1ully alert

Vital Signs

'lood Pressure : )?@ ""H+ Heart rate : 6 p" 9re+ular; /espiratory /ate : 2 ti"es?"inute Te"perature : 8@ oC

'ody ei+ht : 5* k+ 'ody Hei+ht : )06 $" '#I : 2.* 9!or"o4ei+ht;


9/20

G$%$ra& E(a'i%ai!%

Head : !or"o$ephal

Bye : pale $on 9=;, nor"al T)=

T), pale "outh "u$osa 9=;, dried "u$osa 9=;

!e$k : ly"ph nodes enlar+e"ent 9=;


10/20

Thora>: sy""etri$, inter$ostals retra$tion 9=;

COR

Inspe$tion: I$tus $ordis 9=;

Palpation: heae 9=;, lit 9=;, thrill 9=;

Per$ussion:

/i+ht order: IC V, linea "id$lai$ularis de>tra

Left border : IC V, linea "id$lai$ularis sinistra

Heart 4aist: IC IV, linea parasternal sinistra

Aus$ultation : re+ular )st and 2nd heart sound, "ur"ur 9=;,

+allop 9=;


11/20

PULMO

• Inspe$tion : $hest 4ithin nor"al shape, sy""etri$ on stati$ and

dyna"i$ state• Palpation : ta$tile o$al re"itus oth lun+s 4ere sy""etri$, $hest

e>pansion sy""etri$

• Per$ussion : resonant oth lun+s

• Aus$ultation : esi$ular reathin+ sounds, rales 9=?=;, 4heeDin+ 9=?=;

Ado"en : lat, not distended

ti"pani, spleno"e+aly 9=;, hepato"e+aly 9=;,

pain tenderness 9=;

B>tre"ities : 4ar", pete$hiae on e>tre"ities 9=;, C/T E 2 se$onds,

torniFuet=


12/20

La)!ra!r" R$s*&s

He"o+loin: )).0

euko$yte : 3.8

Tro"o$yte : )5*.

He"ato$ryte : 82

idal :

P.Thypi - : )?82

P. Thypi C- : )?82

P. Thypi H : )?)0

P. Th i AH : )?)0


13/20

RESUMEHistory takin+ :

#s. PA, 2 years old, $a"e to the e"er+en$y roo" 4ith $hie $o"plaint o eer ourdays eore ad"ission. 1eer in$reased +radually and elt parti$ularly in the eenin+.Patient also $o"plainin+ aout nausea and o"itin+. he o"ited 6 ti"es, $ontainedood and 4ater, 4ith olu"e 7 8 "l. Heada$he 9;, 4eakness 9;, $onstipation 9;sin$e 3 days a+o. Patient $onsu"ed para$eta"ol ut there is no i"proe"ent.

Physi$al e>a"ination :

Coated ton+ue 9;

aoratory results :

He"o+loin: )).0

idal :

P.Thypi - : )?82

P. Thypi C- : )?82

P. Thypi H : )?)0 P. Thypi AH : )?)0


14/20

Lis !# Pr!)&$'s

DIAGNOSIS

Working diagnosis

Typhoid Fever

Dierential diagnosis %en+ue eer


15/20

Disc*ssi!%

History takin+ eer our days eore ad"ission9in$reased +radually and elt parti$ularly in the eenin+;.

nausea and o"itin+96 ti"es, $ontained ood and 4ater, 4ith olu"e 7 8 "l;

Heada$he 9;

4eakness 9; $onstipation 9;

Physi$al e>a"ination :

Coated ton+ue 9;

aoratory results :

He"o+loin: )).0 idal :

P.Thypi - : )?82

P. Thypi C- : )?82 P. Th i H : ) )0


16/20

P&a% a%+ Tr$a'$%

!on=phar"a$olo+i$alinterentions:

'ed rest

%ia+nosti$ plans: Tue>

I+# I+G anti den+ue

Phar"a$olo+i$al interentions:• IV1% Aserin+ 8 tp"• -"epraDole in3 "+• -ndansentron in3 "+•

Vit C in) a"p• Para$eta"ol 8>) ta prn


17/20


18/20


19/20

Pr!,%!sis

uo ad Vita" : ona"

uo ad 1un$tiona" : ona"

uo ad anationa" : ona"


20/20

THANK YOU

Documents

Lapjag Igd 9 Maret